HomeMy WebLinkAbout02-01-2021 Septic Pumping/inspection reportProperty Owner, i`\ u -�
Street Address: � r. iZj�iyle3�isai ( Pcd
City/Zip Code:
Septic Site Address if Different from Homeowners Address:
Street Address:
City /Zip Code:
Number of Tanks Pumped: Type of Tanks: Tanks Pumped via: Total Volume Pumped:
❑ 1 Precast M Manhole / Riser Manhole(s) to Grade? es No
❑ 2 Combo Inspection Pipe Manhole Covers Secure? e ! No
X3 0 Plastic Baffles:e / No
Other: ❑ Cesspool
Pumping Date-.J/t MPCA License#. Maintenance Provider Name: � �i ES �
Septic system comments:
`Minnesota state taw requires septic tanks to be evaluated every 3 years.
"This postcard does not require postage and our address is pre -addressed. Please call (612) 543-5200 with any questions. Thank you.
IMINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
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 certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional.
Instructions: 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 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. 70802450, 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 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 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
Date of maintenance (mm/ddtyyyy): Reason for maintenance;1� Al? t
Property address: l ��_ 2i-7 ( �.4 t� _ _ Parcel ID:
City: &A,- ��. J y Sta e: MAI_ Zip code:
Property owner's name: t;�)c -4. �.o
Property -owner's address if different: _ _
City: _ State: _ Zip code:
Phone number: Email address:
1. Did you measure the accumulation of scum and sludge?_ -E Yes ❑ No (tank(s) pumped without measuring)
Tank (check if present) Scum Sludge _ Operating depth Percent full
,,�e ticp /holding tank #1 _
Se tic/holding tank #21._ F1 Pretreatment Pretreatment tank
tank
"Pum
2. gf]Access used to remove septage_ ,, Maintenance hole ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? ,�es ❑ No If no, please explain below:
ACTUAL SIZE OF TANKS- TANK#1 TANK#2TANK#3
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 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):
www.pca.state.mn.us 651-296-6300 800-657-3864
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Property address: �2—j 0
Parcel ID:
City: D'rd nn
State:®�
Zip code:
5. Is the tank designed as a leaky
tank? (Example: seepage pit, cesspool, dlywell, leaching pit)
Tank #1: ❑ Yes 2No
Verification method used:
Tank #2: ❑ Yes--ffNo
Verification method used:
6. Is there evidence of the following?
Maintenance hole cover is
Tank leaks below the
Tank leaks above the
damaged, cracked, unsecured, or
Ta k (check if present)
designed operating depth
designed operating depth
appears to be structurally unsound
Septic/holding Tank #1_
❑ Yes No
❑ Yes jZrNo
❑ Yes
Septic/holding Tank #2
❑ Yes No
_ _ ❑ Yes/No
_ ❑ Yes.] No
❑ Pretreatment Tank
❑ Yes El No
❑ Yes El No
-
_ ❑ Yes ❑ No
.'Pump Tank
❑ Yes No
0 Yes No
E] Yes No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #0 � ()_ Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage takenWastev"ter treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #):
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. List any troubleshooting and minor repairs completed or declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping 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 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.
Company informati in F Employee informatio
Company name: / �� 1 ( _ Print name: (
✓
5_
Business license number: D6� _ Certification number: (if applicable):
Email: Phone number: <-/ 6i0
Employee's signature: =/G65'�' Date (mm/dd/yyyy):--
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