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MinnesotaPoitution SSTS Abandonment <br /> Control Agency <br /> 520LafayetteRoadNorth Reporting Form <br /> SC Paul,MN 55155-4194 <br /> Subsurface Sewage Treatment Systems(SSTS) Program) <br /> Instructions <br /> This form is offered to meet the abandonment requiremeMs of Minn.R.70802500 and Disclosure Requiremerrts of Minn.Stat. <br /> §115.55,subd.6.Future water supp�y well placemertt 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 govemment unit(LGU) <br /> within 90 days after the abandonmerrt.This form may be completed by a certified SSTS practitioner or by an individual who has <br /> direct knowledge of how the system was abandoned. <br /> Property Information <br /> Date of abandonment: (�� Reason for abandonment: IV�__W��,� <br /> �7�r�- <br /> a- �' a�ec.� .Sa-:S ED( .,c._c,c�J`•�. �o.i�i-..c ar <br /> Property owner name(s): ' :G��t�-�� ���n 5�40'- <br /> Property owner's address: �`_s��C c ,�:„e _�t�Q�Q__,_ j v z��i e <br /> City: O �c.,2 6 � State: ln n_ --- <br /> Zip: <br /> Site address(if different): _�_ - <br /> ��ri: otano -- '��t� <br /> Zip: <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? Yes ❑No <br /> Disposal Site: �('� �r �-hnn�1- <br /> 1��I <br /> 2. All electrical devices and devices coMainin�ry removed?�Yes ❑No - <br /> Disposal Site: <br /> 3. Ali underground sewage tanks crushed and filled with soii or rodc material7 Yes ❑No or <br /> Removed and disposed off sde? ❑Yes ❑No <br /> Disposal Site: <br /> 4. Contaminated material�ed and disposed off site? ❑Yes ❑No <br /> Disposal Site: <br /> 5. All underground qvities"crushed and filled with soil or rxk material� ❑Yes ❑No or. <br /> Removed and disposed off sfte? ❑Yes ❑No <br /> Disposal Site: ��___ . <br /> 6. Future discharge to system pertnanently denied7�es ❑No <br /> Method(s)used: <br /> 'Contaminated materials=Distribution media,soil arsand within three feet of the sysfem bottom,distribution pipes,geotextile <br /> fabric/rasin paper/straw,tanks,contaminated soi/around leaking tanks,any soil that recei�red sewage <br /> from a surface failure(7080.2500 subp.3). <br /> "Underground cavities= Cesspop/s,leeching pits,drywells,seepage pits,vault privies,pit p�ivies,pump chambers <br /> (7080.2500 subp. 1).Does rrot include chamber media,drop boxes,or distribution boxes. <br /> www.pca.state.mn.us • 651-296-8300 • 800-657-3864 • T7Y 651-2ffi-5332 or 800-657-3884 • �Available in altemative fortnats <br /> wq-wwlsts4-03 • 11/21/08 <br /> Page 1 0l2 <br />