HomeMy WebLinkAbout11/12/2021 Septic Compliance InspectionMMINNESOTA 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 compiles with 1he 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 certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional.
Instructions: A oopy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained
by the licensed SSTS maintainer 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 135
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 flipped. 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 burled 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
Date of maintenance (mm/ddtyyyy): 11/12/2021 - Reason for maintenance: 3 Year Tank Pumping
Property address: 1580 County Rd 6 (6th Ave N). _ _ Parcel ID: 261182a320DD6_
City: Orono -_ _ State: MN— _ zip code: 55356,
Property owner's name: Darin F l * I
Property -owner's address if different: -
City: - - - State: - - - - - Zip code:
Phone number. ` _ _- _ Email address:
1. Did you measure the accumulation of scum and sludge? ❑ Yes ]R No (tank(s) pumped without measuring)
_Tank (check If present)_ _ _Scum Sludge _ Operating depth _Percent full
Se I:iclholding tank #1 - -- - --.- - - -- - - -- i - - - -
0Septic1holdingtank.#2 - -- - - - - • - - -
QPretreatmenttank
O Pum�tank-
2. Access used to remove septage: ® Maintenance holes ❑ other (Unless a holding tank, go to #4 below)
(�� concrete
3. If the maintenance hole was used, were covers secured in place? ®Yes ❑ 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.
I, refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's 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 typinglsfgning 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 (mm/dd/yyyy):
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Property address: „1580 County Rd 6 (6th Ave N)_ ___.. _ _. _. Parcel ID: 2611823320006
city: .. Orono _ State: MN' .. _ __ zip code: _55356
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, dryweil, leaching pit)
Tank #1: ❑ Yes 9 No Verification method used: Visual when empty
Tank #2: ❑ Yes 0 No Verification method used: Vlaval when empty
G. Is there evidence of the following?
Maintenance Note cover is
Tank tc Lack if presentt __.
Tank teaks below the
designed operating depth_
Tank teaks above the I damaged, cracked, unsecured, or
designed opera f_dng epth _ vpears to be structurally unsound ,
_RSeptid pIdin Tank #1 _
_ 0 Yes _® No --
_ _ . _ Yes ®No _
__ + _ IT*
Rl Septialholding Tank#2
❑ Yes _J@No
_rl yes RNo
—0—yes ENP
Pretreatment Tsnk - _-_
❑ Yes El No
_ Yes_ Q No---
_ _ [j Yes No
_
Pum Tp ank --
_ (� Yes ® No_ ..
❑ YesZ No
Describe detail for any `Yes"
7. How many gallons of septage were removed?
Tank #1: 1250 Tank #2: 1250 Pretreatment Tank: Pump Tank: 100
8. Where was the septage taken? E Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): Watertown, M N
9. Did you identify any operational Issues or unsafe conditions whits assessing the sewage tanks in this system?
❑ Yes ® No If yes, identify tank and explain:
❑ Evidence of non-domestic waste ❑ Baftle(s) condition ❑ Effluent screen condition
❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, eta)
Explanation:
10. List any troubleshooting and minor repairs completed or declined by owner:
switch. All baffles present & in good condition.
Additional comments or suggestions for owner's consideration:
Pumping record
I personally conducted the work described above on behalf of a Minnesotedicensed SSTS Maintenance Business, in compliance
with M/nnesote Rules Chapters 7080 - 7083:
❑ As a noncertiffed individual who has received proper training, daily work review, and periodic observation, or
IRAs a designated certified individual of the business listed below.
By 010 ping 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 Employee Information
Company name: Albin's_ Septic Pumping, LLC Print name: Peter Peterson
Business license number: 3346 Certification number: (if applicable): 9227f
Email: albinssepticpum ' g ahoo.com Phone number: 612-559-3456
Employee's signature:'" Date (mmlddMrYY)
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1580 County Rd 6 (6th Ave N�_ _ Parcel ID: 2611823320006
Property address: �
City; Orono State: MN __ Zip code:. 55356
-_
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,
rtified
Instructions:
B Business who personally ally conducts thcompleted pecessary roceduresgned by a Dt a'ssessdtheecompl individual
statusDofilicensed each s
Maintenance 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: n form Existing system (wa-+srwists4-31b1. This form can be
found on the MPCA website at https:/hvww.pca.state.mn.ustwateriservice-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 SETS
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_ 7nfi2.n700. subp. 4 hems B, C, and D; 7083.0730 Item C.
® Certificate of sewage tank compliance
Affirm all three statements:
The SSTS does not contain a seepage pit, cesspool,
drywall, 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.
$J It does not represent an imminent safety threat by
reason of unsecured, damaged, or weak
maintenance hole cover(s) or other unsafe condition.
❑ Notice of sewage tank non-compliance
Select all that apply:
❑ The SSTS has a seepage pit, cesspool, drywall,
leaching pit, or other pit — "Failure to Protect
Groundwater."
❑ 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."
Company information Designated Certified Individual (DCI) Information
Company name: Albin's Septic Pumping, LLC-.._-". Print Warne: „Peter Peterson_
Business license number: 3346 _ Certification number: 9227
I personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SSTS Maintenance
Business. t personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS.
By typing/signing my name below, I certify the above stat encs to be true and correct, to the best of my knowledge, and that
this Information can be used for the purpose of pro i.. form.
Designated Certified individual's signature: Date (mmlddtyyyy):_ 11 /12/2021_ _
"--
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