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�.� . <br /> �� Minnesota Pollution SSTS Abandonment <br /> Control Agency <br /> 520 lafayette Road North Re p o rt i n g Fo r m <br /> St 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 pfacement can also be affected by an abandoned SSTS. <br /> The use of this fortn is not mandatory;however the information on this foRn must be submitted to the local govemment unit(LGU) <br /> within 90 days aRer the abandortment.This fortn may be completed by a certified SSTS practitioner or by an individual who has <br /> direct knowtedge of how the system was abandoned. <br /> Property Information <br /> Date of abandonment: `'Z"U ' � � Reason for abandonment: <br /> Property owner name(s): <br /> Property owner's address: <br /> City: �� State: �..�� Zip: <br /> Site address(if different): <br /> City: State: Zip: <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? �$Yes ❑No <br /> Disposal Site: <br /> 2. All elecUical devices and devices containing mercury removed? ❑Yes ❑No N/A <br /> Disposal Site: <br /> 3. All underground sewage tanks crushed and filled with soil or rock material? �Yes ❑ No or <br /> Removed and disposed off site? ❑Yes �No <br /> Disposat Site: <br /> 4. Contaminated materials'removed and disposed off site? (�Yes ❑No <br /> Disposal Site: <br /> 5. All underground cavides"cnished and filled with soil or rock material7 �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 /> •Contaminated moterlals= Dtstributlon medlo,soll or sand withfn three feet of the system bottom,dlstributlon pfpes,geotextile <br /> febrtc/rasin paper/strew, tonks,contominoted soll around leaking tanks,arry so11 that received sewage <br /> from a surface fo!lure(7080.2500 subp.3). <br /> •'Urtdergrourtd covltles e Cesspools, leaching pfu,drywel(s,seepage plu, vault priv�es,p�t prlvies,pump chombers <br /> (7080.2500 subp. 1). Does not fnc(ude chamber medla,drop boxes,or d�stributfai boxes. <br /> www.pca.state.mn.us • 651-296-6300 • 800•657-3864 • TTY 651-282-5332 or 800-657•3864 • Available in altemative formats <br /> wq-wwfsts4-03 • 11/21l08 Poge 1 of 2 <br />