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� PaFc�t number: �� ' �/� -- 0�3 ' �7� ` C C�' � System status: ❑ Compliant �Noncompliant (as determined by this form) Certificate of Abandonment Date of observation: � -- —/5 Reason for obsenration: ,��/�C� �GJ ,��j ✓� ��f,� Compiiance quesxionslcriteria: (Check the appropriate box) To be in compliance,syst�ms with no future intended use for sewage or clean water discharge must be abandoned in accordance Minn. R.7080.2500 as determined below: Were aii the solids and liquids removed fcom the system? ,�]]Yes ❑ No Were all electrical devices and devices containing mercury removed? ,�Yes ❑ No Were all underground tanks removed or tanks crushed and filled with soil or rock material? �'Yes ❑ No Were all underground cavities removed or filled with soil or rock material? �'�Yes ❑ No *Any"no"answers indicates the system is failing to protect ground water Property owner name(s): �]/�✓�,�E �% /�JC,�tis'� v'�.�� Property address: � � C��,��'� ��j �,`� ��G'�%G� Property owner's address('rf different): S .�-� Q �. � r County: ��t1Nj.Q�2 N Phone: �i�,� � ' � � — �S �,� � Certification This form is to be completed and attached to the Summary Forrn of the Minnesota Pollution Control Agency's(MPCA)Compliance Inspection Fortn for Existing Subsurface Sewage Treatrnent Systems(SSTS).This form does not have to be completed by a certfied SSTS practitioner, but must be completed by the individual who has knowledge of how the system was abandon. Completed form must be submitted to the tocal unit of govemment within 90.days. I hereby certify the sysfem was abandoned in accorda�ce with Minn. R. 7080.2500 and any local requirements. Name: ,//,R T�C�,,i(� � ; ��'e��i--' Certification number: � �� Business license name and n ber: �u�Q � . ��%��/`�r✓ ,j� Business addres � �� u / '��} ��J `�t, ,� �j� �'S�� ' Signature: Date of abandonment: ,� -� �`� wq-wwists4-31 Comp(ronce Inspection Form for Existing SSl'S 4/1/08