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Minnesota Pollution Control Agency SSTS Abandonment <br />520 Lafayette Road North Reporting Form <br />St. Paul, MN 55155-4194 <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 individual who has <br />direct knowledge of how the system was abandoned. <br />Property Information <br />Date of abandonment: 9/13/2024 <br />Property owner name(s): <br />Property owner's address <br />City: Orono <br />Site address (if different): <br />City: <br />Bradley Pass <br />Reason for abandonment: Demo of structure <br />215 north arm lane <br />Compliance Information <br />1. All solids and liquids removed from all tanks? ® Yes ElNo <br />2 <br />3 <br />Disposal Site: City of Waconia, inn <br />State: inn <br />State: <br />All electrical devices and devices containing mercury removed? ®Yes ❑ No <br />Disposal Site: <br />All underground sewage tanks crushed and filled with soil or rock material? ❑Yes ❑ No or <br />Removed and disposed off site? ®Yes ❑ No <br />Disposal Site: Bursch Brothers Inc. recycle yard <br />4. Contaminated materials* removed and disposed off site? ❑Yes ❑ No <br />Disposal Site: NA <br />5. All underground cavities** crushed and filled with soil or rock material? ®Yes ❑ No or: <br />Removed and disposed off site? ❑Yes ❑ No <br />Disposal Site: <br />6. Future discharge to system permanently denied? ®Yes ❑ No <br />Methods) used: All piping rem <br />Zip: 55364 <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 TTY 651-282-5332 or 800-657-3864 Available in alternative formats <br />wq-wwists4-03 11/21/08 Page 4 of 2 <br />