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r <br /> Minnesota Pollution SSTS Abandc�nment <br /> Control Agency <br /> 520 Lafayette Road Narth Re p o rt i r��g Fo rm <br /> St.Paul,MN 55155-4194 <br /> Subsurface SewaBe Tr�atment Systems (SS?P�) Program) <br /> Instructions <br /> This form is offered to meet the abandonment requiremerrts 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 local goverrment unit(LGU) <br /> within 90 days after the abandonment.This form may be completed by a certified SSTS practitioner or by an individual who has <br /> direct knowledge of how the system was abandonetl. <br /> Property Information <br /> Date of abandonment: _ �p��� —IS Reason for abandonment: L w S�/���,.,�._ ,� ;., ' i � <br /> Property owner name(s): ��h n �.��_ <br /> Property owner's address: __ .�'3 3 �/�„ �� �•;..,�. <br /> Ciry: U�'iln� --- --- State: /YJ�Y Zip: _ -- <br /> Site address(rf different): <br /> -- <br /> _._. __ __ _. <br /> Ciry: ___ __ _ State: - - — Z�p� — <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? �Yes ❑No <br /> Disposal Site: �v.:h �� 5,�,�'f: c <br /> 2. All electrical devices and devices containing mercury removed? ❑Yes �No <br /> Disposal Site: _ /�Cn.;� <br /> 3. All.underground sewage tanks crushed and filled with soil or rock material? �j Yes ❑No or <br /> Removed and disposed off site? ❑Yes ❑No <br /> Disposal Site: <br /> 4. Contaminated materials*removed and disposed off site? ❑Yes j� No <br /> Disposal Site: V1 p i�•z <br /> 5. All underground cavities**crushed and filled with soil or rock material? ❑Yes Q No or: � <br /> Removed and disposed off site? ❑Yes ❑No <br /> Disposal Site: _ ����� <br /> 6. Future discharge to system permanently denied? �7 Yes ❑No <br /> Method(s)used: <br /> 'Contaminoted materials= Distribution media,soi(or sand within three feet of the system bottom,distribution pipe��,,geotextile <br /> fQbric/rosin paperJstraw, tanks,contaminoted soil around leaking tenks,arrysotl thatreca_ived sewage <br /> from a wrface fai(ure(7080.2500 subp.3). <br /> "Underground cavities= Cesspoo(s, leaching pits,drywells,seepaqe pi[s,vaulC privies,p)t privies,pump chamber:; <br /> (7080.2500 wbp. 1). Does not include chamber medio,drop boxes,or distri6ution 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-wwists4-03 . 11/21/08 Page 1 of 2 <br />