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RECEIVED <br /> Minnesota Pollution �u� 2 o zo�� SSTS Abandonment <br /> �"�-,..:;= Control Agency <br /> V szo�arayecce Roaa rvo�cn G�`{y O�ORON4 Re p o rti n� Fo r m <br /> SL Paul,MN 55155-4194 <br /> Subsurface Sewage Treatment Systems (SSTS) Program) <br /> Instructions <br /> This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat. <br /> § 115.55,subd.6. Future water supply well placement can also be affected by an abandoned SSTS. <br /> The use of this form is not mandatory; however the information on this form must be submitted to the locai government unit(LGU) <br /> within 90 days after the abandonment. This form may be compieted by a certified SSTS practitioner or by an individual who has <br /> direct knowiedge of how the system was abandoned. <br /> Property Information <br /> Date of abandonment: 06-07-2016 Reason for abandonment: New Home Const�uCtion <br /> Property owner name(s}: Christopher& Katie Loveless ______��� . <br /> Property owner's address: 3960 Bayside Rd <br /> City: --����� ��"0 i'1[� State: MN _ Z�p; 55359 <br /> Site address(if different): <br /> City: State: Zip: <br /> Comptiance Information <br /> 1. AII solids and liquids removed from ail tanks? �Yes ❑ No <br /> Disposal Site: _,. <br /> ___.__-----------_.._____.. — — -- <br /> 2. Ail electrical devices and devices containing mercury removed? �Yes ❑ No <br /> Disposal Site: <br /> 3. Ail underground sewage tanks crushed and filled with soil or rock materiai? �Yes ❑ No or <br /> Removed and disposed off site? ❑Yes ❑ No <br /> Disposal Site: <br /> 4. Contaminated materials'removed and disposed off site? �Yes ❑ No <br /> Disposal Site: ---- <br /> 5. AII underground cavities*'crushed and filled with soil or rock material? (�Yes ❑No or: <br /> Removed and disposed off site? ❑Yes ❑ No <br /> Disposal Site: _ � — -- — <br /> 6. Future discharge to system permanently denied? �Yes ❑ No <br /> Method(s)used: - — <br /> 'Contaminoted materiais= Distribution media,soit or sand within three(eet oj the system bottom, disfribution pipes,geotextite <br /> fabric/rosrn paperlstraw, tanks, contaminated soil around leaking tanks, ony soil that received sewage <br /> from a sur�ace(oilure{7080.2500 subp.3). <br /> "Underground cavities= Cesspools, (eaching pics, drywetls,seepage pits, vault privies,pit privies,pump chambers <br /> (7080.2500 subp. 1). Does not inc(ude chamber medra, drop boxes, or distribution boxes. <br /> -- ----- __.....--------_--....---- <br /> www.pcasta[e.mn.us • 651-296•6300 800-657-3864 � TTY 651-282-5332 or 800•657-3864 • Available in alternative formats <br /> wq-wwists4•03 • 11/21/08 P�3e ��f z <br />