HomeMy WebLinkAbout04-26-23 Septic MaintenanceMINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SSTS) Program
Doc Type. Compliance and Enkfcement
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 7082.0800. 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 data. Maintenance reporting to the local unit of
government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol. Page 3 is
optional and not required to be comptetsd on routine maintenance events.
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 looked, boiled 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 tical 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 I i
Date of maintenance (mmid
Property address: _511n;
City: �}� * -z-OM
Property owner's name:
Property -owners address (if
City:
Phone number.
4 K
Reason for
State: ttN tJ Zip code:
State:
Zip code:
Email address:
Did you measure the accumulation of scum and sludge? A Yes ❑ No (tank(s) pumped without measuring)
E]Other (Unless a holding tank, go to #4 below)
If the maintenance hole was used, were all covers secured in place? [�Ies ❑ No If no, please explain below
Actual Size- Tank#1 Tank #2 Tank #30Pump Tank
/5[�)o /SCXD /500
fl, the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintena
hole, have them complete and sign the following statement.
I 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 door not fulfil 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, an
that this information can be used for the purpose of processing this form.
Owners signature: Date (mm/dd/yyyy): _
www.pma.state.mn.us 651-2W6300 • 804657-3864
wq- wW54-38 • 4/28/21
nee
d
• Use your preferred relay service Available in alternative formats
Page 1 of 3
Property address:
City:
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pd)
Parcel ID:
Zip code:
Tank #1: ❑ YesNo Verification method used: U IS__y uRL
Tank #2: ❑ Yes f No Verification method used: I, tSkJAL
6. Is there evidence of the following?
Tank leaks below the I Tank Wake above the
Tank #1
Yes
Describe detail for any "Yes"
7. How many gallons of septage were removed? '3
Tank #1: TanK #2: r /j >& Pretreatment Tank:
Maintenance hole cover is
damaged, cracked, unsecured, or
-,Tm
Pump Tank: SZXD
S. Where was the septage taken? 0 Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site t):
9. Did you ntlfy any operational issues or unsafe conditions while assessing the sewage tanks in this system?
❑ Yes No If yes, identify tank and explain:
❑ d nee 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:
0 As a noncertified individual who has received proper training, dairy work review, and periodic observation, or
❑ As a designated certified individual of the business listed below.
By typing/signing my moors 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: Mike's Septic & McKinley Sewer
Business license number: L 19385 & L2899
Email:
Employee's signature:
Employee it#oNnation
Print name: i" % ` VIJQ tnJ lea \ gtA[fS— —
Certification number. (of applicable):
Phone number. 952.440.1800
Date (mm/dd/ylyyy)-
vmw.pca.state.rnn.us 651-296.6300 800.6573864 Use your preferred relay service Available in alternative formats
wq-wwist54-38 • 4118/21 Page of