HomeMy WebLinkAbout10-02-2021 - septic maintenance reportMINNESOTA POLLUTION Sewage tank
CONTROL AGENCY
520 Lafayette Road North maintenance reporting form
St. Paul, MN 55155-4194 Subsurface SeWage
Treatment Systems (SSTS) Program
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance
requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank
components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may
only cerdfy sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional.
Insumdons: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained
by the licensed SSTS maintalner business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of
government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol.
Secure maintenance hole covers
All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding
the anticipated load.
Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D:
a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95
pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and
not susceptible to being slid or dipped. They must have a label warning of hazardous conditions inside the tank. All screw
openings must be refastened.
b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of
soil cover or be secured according to the local ordinance in effect before February 4, 2008•
C) Covers must meet item `a' above when raised to the ground surface or less than 12 inches from the ground surface
Reporting information
Reason far maintenance: Maintenance &Compliance Inspection
Date of maintenance (mm/dktlyyyy): 10/02/2,021 ..__T _ Parcel ID: 041172343000_
Property address: 2675 Fox St
City; Orono— — _ —
State: -MN _.. _ . Zip code: 55391
. _ _ _ --
Property owner's name: Victoria Ter
Property -owner's address if different:
City: _ State:_ _ Zip code: __ ,--
Phone number: 612-730-1081 _ Email address: victoriaterryl Cc�msn corn -
1. Did you measure the accumulation of scum and sludge? ® Yes jg No (tank(s) pumped without measuring)
Tank(check if -resent) -- Scum _Sludge _ operating 4Vth Percent full
$� SeAIglholdin tank #t
_RSep !pthl olding tonic #2—
Q Pretreatment tank
®_Pgrn�tank-
2. Access used to remove septage: gl Maintenance holes ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? 0 Yes p No If no, please explain below:
4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
hole, have them complete and sign the following statement.
l _ refuse to allow the removal of the solids and liquids through the maintenance
(print owners name) _
hole. i understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and
that this information can be used for the purpose of processing this form.
Owner's signature: _ _ -- Date (mmldd/yyyy):
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wq-wwists4-38 • 3/7/21
Property address: 2675 Fox St - Parcel ID: 0411723430003
city: Orono state: MN zip code: 55391
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: ❑ Yes ❑ No Verification method used: _ Tank #2: ❑ Yes ❑ No Verification method used: -
S. Is there evidence of the following?
intanan hole cover is
Tank;check If presentZ _ _ _ ..
Sep#clhoidin Tank #1
Septiclholding Tank #2
Pretreatment Tank _
Describe detail for any "Yes"
Tank leaks below the
designed operating depth
Tank leaks above the
designed operating depth_
� Ma ce
damaged, cracked, unsecured, or
�.>_ appeaMto bi st^ict ally unsound
Yes
Na
Yes � No _
No
-+ �- .Y�es -------
_ _[7
❑ Yes_No
_�I
. ❑ Yes. _No YesNo
® Yes
❑ No
Yes [jNo�
-F.. fl Yes No _- —
_❑ Yes
0 No_
El Y@;;__0 No , _ _
Yes No
� �� o.._
7. Now many gallons of septage were removed?
Tank #1: 1000 Tank #2: 1000 Pretreatment Tank: x Pump Tank: 100
8. Where was the septage taken? 0 wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): _Vllatertown, M N - — —� -
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
[:]Yes ® No If yes, identify tank and explain:
❑ Evidence of non-domestic waste ❑ Baffle(s) condition ❑ Effluent screen condition
❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
Explanation:
10. hist any troubleshooting and minor repairs completed or declined by owner:
X Troubleshooting and repairs conducted: Y ❑ Repairs declined by
RenlarPd alarm float switch in the Dump tank.,
Cleaned effluent filter w/alarm in 2nd tank outlet.; _
Additional comments or suggestions for owner's consideration:
Pumpinr record
I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083:
❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or
�$( As a designated certified individual of the business listed below.
By typinoigning my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that
this information can be used for the purpose of processing this form.
Company information
Company name: Albin's Septic Pumping, LLC
Business license number: 3346
Email: albinsseptic uymp ing ahoo.com
Employee's signature:
Employee information
Print name: Peter Peterson
Certification number. (if spoicgue): 9227 e
Phone number. 612-559-3456 _
-�- - Date (mm/ddJ"):_ 10/02/2021 _ _ _—
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Property address: _ 2675 Fox St Parcel ID: 0411723430003_
__
city: Orono state: MN -_- Zip code: 55391_ _
optional section: Sewage Tank Compliance Certification (Tank integrity assessment)
This form does not represent a complete system inspection report and only certifies sewage tank compliance status. i.e.,
this form, completed, may serve as a tank integrity assessment.
Instructions; This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS
Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in
the system.
When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentation to an
Existing System Compliance Inspection Report: Compjiance in pection form Existing system (wg-vrwists4-31 b). This form can be
found on the MPCA website at https:/Mww.pca.state.mn.ushvaterlservice-and-maintenance.
The information and certified statement on this form is required when existing septic tank compliance status is determined by an
individual other than the SSTS Inspector that submits an inspection report. This form represents a third party assessment of SSTS
component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of
three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is
required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn.
R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C.
0 Certificate of sewage tank compliance
Affirm all three statements:
$� The SSTS does not contain a seepage pit, cesspool,
drywell, leaching pit, or other pit.
It does not contain a sewage tank that was designed
to be watertight, but subsequently leaks below the
designed operating depth.
® It does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
maintenance hole cover(s) or other unsafe condition.
Company information
Company name: Alb_i_n's Septic Pumping, LLC
3346
❑ Notice of sewage tank non-compliance
Select all that apply:
[] The SSTS has a seepage pit, cesspool, drywell,
leaching pit, or other pit — "Failure to Protect
Groundwater."
E] It has a sewage tank that was designed to be
watertight, but subsequently leaks below the designed
operating depth —"Failure to Protect Groundwater."
[] It presents a threat to public safety by reason of
unsecured, damaged, or weak maintenance hole
cover(s) or other unsafe condition — "Imminent Threat
to Public Health or Safety."
Designated Certified Individual (DCI) information
Print name: Peter Peterson _
Business lrcense number. Certification number: 9227 a _
1 personally conducted the work described above as a Designated Certified Individual of a Mlnnesota4censed SSTS Maintenance
Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS.
By typingfsigning my name below, I certify the above. statements to be true and correct, to the best of my knowledge, and that
this infonnedon can be used for the purpose of p ee sng�th' form.
Designated Certified Individual's signature: Dye
--- — — Date (mmlddlyyyy);_ 10/02/2021_
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Site address:
2021 SEPTIC MAINTENANCE REPORT
2675 Fox St ( Victoria Terry )
Number of tanks: 3 Date last pumped: 10/02/2021 Gallons pumped: 2100
Name of pumper / maintenance provider:
Are tanks watertight?:
Is the system functioning properly? Yes
Albin's Septic Pumping, LLC
YES NO
(please circle one)
(ie slow drainage, wetness in the drainfield?)
Do you have any specific concerns or issues that you'd like to discuss with the SSTS Program Manager?
No
if so, please indicate best time and telephone number(s) to be reached between 8 am and 4:30 pm.
Best Times
Alicia Johnson
Telephone Number(s)
RETURN IN THE ENCLOSED ENVELOPE
AS SOON AS POSSIBLE
CITY OF ORONO
PO BOX 66
CRYSTAL BAY MN 55323-0066