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• <br /> Minnesota Pollution <br /> Control Agency SSTS Abandonment <br /> 520 Lafayette Road North <br /> St.Paul,MN 55155-4794 Reporting Form <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 individu hc>.h, s , <br /> direct knowledge of how the system was abandoned. <br /> Property Information OCT 2 8 <br /> 2014 <br /> Date of abandonment: Z3 ce Reason for abandonment: NGi.t) <br /> - e ."1/1°40 <br /> Property owner name(s): /'l L/( C,A-e/SO 0 <br /> Property owner's addres : <br /> City: / (> <br /> 11 C, YL' fit-/ 114 1` State: 4/1 Gam/ <br /> Site address(if different): Zip: <br /> City: <br /> State: Zip: <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks?J Yes 0 No <br /> Disposal Site: «i 7 A' e <br /> 2. All electrical devices and devices containing mercury removed? AYes El No <br /> Disposal Site: <br /> 3. All underground sewage tanks crushed and filed with soil or rock material? Yes El No or <br /> Removed and disposed off site? 1:1 Yes allo <br /> Disposal Site: <br /> 4. Contaminated materials*removed and disposed off site'? M Yes ❑ No <br /> Disposal Site: <br /> 5. All underground cavities**crushed and filled with soil or rock material? ij"Yes ❑ No or: <br /> Removed and disposed off site? 0 Yes g No � <br /> Disposal Site: <br /> 6. Future discharge to system� permanently denied? Yes 0 No <br /> Method(s)used: l�(it /C;, .c Ji eJ <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= 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 <br /> • <br /> wq-wwists4-03 • 11/21/08 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br /> Page 1 of 2 <br />