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• <br /> i <br /> s <br /> Minnesota Pollution SSTS. Abandonment <br /> Control Agency <br /> 520 Lafayette Road North Reporting Form <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 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 government 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 abandoned. <br /> Property Information <br /> Date of abandonment: (7 ) <br /> 20//41 Reason for abandonment: 1\16c.4-) 9'y�'e(N( <br /> Property owner name(s): j1 l(/t l"A2L,50 j /' <br /> Property owner's` addres : <br /> City: I/30 0 I CYC/Si4-I 6, f.d State: AO ''Z1 Zip: <br /> Site address(if different): <br /> City: State: Zip: <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? Yes 0 No <br /> Disposal Site: £17 A 4' <br /> 2. All electrical devices and devices containing mercury removed? fYes 0 No <br /> Disposal Site: <br /> 3. All underground sewage tanks crushed and filed with soil or rock material? Yes 0 No or <br /> Removed and disposed off site? 0 Yes ES,No <br /> Disposal Site: <br /> 4. Contaminated materials*removed and disposed off site? 15Ia Yes 0 No <br /> Disposal Site: <br /> 5. All underground cavities**crushed and filled with soil or rock material? res 0 No or: <br /> Removed and disposed off site? ❑Yes ®No 'l <br /> Disposal Site: \\ <br /> 6. Future discharge to system permanently denied?f R Yes 0 No <br /> Method(s)used: Cud C✓LQ/y/dd <br /> *Contaminated materials= Distribution media,soil or sand within three feet of the system bottom,distribution pipes,geotextile <br /> fabric/rosin paper/straw, tanks,contaminated soil around leaking tanks, any soil that received sewage <br /> from a surface failure(7080.2500 subp.3). <br /> **underground cavities m Cesspools, leaching pits,drywells,seepage pits, vault privies,pit privies,pump chambers <br /> (7080.2500 subp. 1).Does not include chamber media, drop boxes,or distribution boxes. <br /> www.pca.state.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 Page 1 of 2 <br />