HomeMy WebLinkAbout860 Brown Rd S - Tank abandonment formMinnesota Pollution Control Agency SSTS Abandonment
520VItte Road North Reporting Form
St. Paulaul,, MN 55155-4194
Subsurface Sewage Treatment Systems (SSTS) Program)
Instructions
This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Slat.
§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS.
The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU)
within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has
direct knowledge of how the system was abandoned.
Property Informati�on� ' _ s
Date of abandonment: 11. 11 1'Ll'/'�1 Reason for abandonment: j7bA;W,j�RW.fj
Property owner name(s):
Property owner's address:
City: _ State: _ Zip: _
Site address ( erent): p�(�__
City: QQ _ state Zip:
Compliance Information
1. All solids and liquidrs removed from all tanks? XYes ❑ Nol.(
Disposal Site:J-(�
2. All electrical devices and devices containing mercury removed? ❑ Yes ❑ No
Disposal Site: 1A___
3. All underground sewage tanks crushed and filled with soil or rock material? KYes ❑ No or
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
4. Contaminated materials* re irJov�nd disposed off site? El Yes ❑ No
Disposal Site:
5. All underground cavities" crushed and filled with soil or rock material? ❑ Yes ❑ No or:
Removed and disposed offs(te? ❑ Yes ❑ No
Disposal Site: N
6. Future discharge to system permanently denied? A Yes ❑ No
Method(s) used:
"Contaminated materials = Distribution media, sail or sand within three feet of the system bottom, distribution pipes, geotextile
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure (7080.2500 5ubp.3).
—Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers
(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes.
www.pca.state.mn.us 651-296-6300 800-657.3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-ww1sts4-03 • 11121108 Page i of 2
Map
Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also
Include a permanent reference point(s) and dimensions.
Certification
i hereby certify the sys
Name (please print): .
Address:
City: f
Phone:
Date: 11 1,2 �!
was
N-
REMOVE EX-m-n I 6US-DRIVEWAY
_ZG
• j
4 0wSH EE-X-+0pUSl
APACE-. \
REMOVE tkISTING UTILITY$ERVIC�S
COORDINATE 1t103H UTItiITY OW MERS
in accordance with Minn. R. 7080.2500 and any local requirements.
eAfl (V(XW— Title: j)_
Signature:
State: Zip:
# if applicable): 111
www.pca.state.mn.us • 651.296-6300 • 800-657-3864 TrY 651.282-5332 or 900-657-3864 Available in alternative formats
wq-WWlsts4.03 • 11121108 Page 2 of 2