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��MINNESOTA POLLUTION <br />CONTROL AGENCY <br />520 Lafayette Road North <br />St Paul, MN 55155-4194 <br />Sewage tank <br />maintenance reporting form <br />Subsurface Sewage <br />Treatment Systems (SSTS) Program <br />Doc type: Complfance and Enfomement <br />Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource <br />protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance <br />requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank <br />components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may <br />only certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional. <br />Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained <br />by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the kcal unit of <br />government may be required by local ordinance. Check with your focal SSTS program for maintenance reporting protocol. Page 3 is <br />optional and not required to be completed on routine maintenance events. <br />Secure maintenance hole covers <br />All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding <br />the anticipated load. <br />Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, items C or D: <br />a) Covers installed under kcal ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be <br />95 pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, <br />and not susceptible to being slid or flipped. They must have a label waming of hazardous conditions inside the tank. All <br />screw openings must be refastened. <br />b) Covers installed under local ordinances adopted before February 4, 2 ^08 must either be buried with at least 12 inches of <br />soil cover or be secured according to the local ordinance in effect before February 4, 2008. <br />c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface. <br />Reporting information <br />Date of maintenance (mmiddyyyy): 41712026 Reason for m:i i ntcnance: Septic Compliance <br />Property address: 4665 West Branch Rd Parcel ID: 07-117-23-22-0015 <br />City: Orono State: _ M: a Zip code: 56364 <br />Property owner's name: Eric Truskoski I Brigitte Hamblin <br />Property -owner's address (if different): 6520 Belle St <br />City: Greenfield State: _ NI N <br />Phone number. 860-866-8489 Email address-. <br />1. Did you measure the accumulation of scum and sludge? ❑ Yes <br />Tank check ifpresent) <br />Scum <br />Slud e <br />Septic/holdingSeptic/holding tank #1 <br />Septic/holdingSeptic/holding tank #2 <br />Pretreatment tank <br />Pump tank <br />Zip code: 55357 <br />IC;'IVo (tank(s) pumped without measuring) <br />! Operating Le h Perrentfull <br />2. Access used to remove septage: IffMaintenance hole ❑ Other (tt.i, ss a holding tank, go to #4 below) <br />3. If the maintenance hole was used, were all covers secured in place? t($,sYes L] No If no, please explain below: <br />4. if the owner refuses to allows Subsurface Sewage Treatment Sys 1, ­, ;9STS) to he pumped through the maintenance <br />hole, have them complete and sign the following statement. <br />I, , refuse to allow the removal : r !lie solids and liquids through the maintenance <br />(Print owners name) <br />hole. I understand that removal of solids and liquids through other acr•o, r,,,ints is not c(,nsidered a compliant method of <br />solids removal and does not fulfill the solids removal requirements of t.:. R. 7080.2450 and 7082.0800. <br />By typirWsigning my name below, I certify the above statements to 1,,:: ue and correct, to the best of my knowledge, and <br />that this information can be used for the purpose of processing this forr: <br />Owner's signature: (rnmidd/yyyy): <br />www.pmstatLrnn.us • 651-296.6300 • 800-657-3864 • Useyourp., rv'jyservice <br />wq-ww1sts4-38 - 41201 <br />Available in alternative formats <br />Page 1 of 3 <br />