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Home My WebLink About2630 Fox Street - Septic ComplianceMM11' NESOTA POLLUTION COATROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form Subsurfaco 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 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. 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 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 ry112 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 (mmldd/yyyy): 1/1312026 Reason for maintenance: Compliance Inspection Property address: 2630 Fox Street Parcel ID: 0411723420027 City: Orono State: MN Zip code: 55391 Property owner's name: Anthony Sarenpa Property -owner's address if different: City: State: Zip code: Phone number: 612-805-6890 _ Email address: 1. Did you measure the accumulation of scum and sludge? ❑ Yes ® No (tank(s) pumped without measuring) Tank (check if present) Scum Sludge Operating depth Percent full ® Septic/holding tank #1 normal level El Septic/holding tank #2 normal level ❑ Pretreatment tank ® Pump tank normal level 2. Access used to remove septage: ❑ Maintenance hole [I Other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all 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. 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. Owner's signature: Date (mm/dd/yyyy): www.pca.state.mn.us 651-296-6300 a 800-657-3864 Use your preferred relay service Available in alternative formats wq-wwists4-38 • 10112118 Page 1 of 3 Property add ess: 2630 Fox Street Parcel ID: 0411723420027 City: Orono State: MN Zip code: 5539.1 5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit) Tank #1; ❑ Yes ® No Verification method used: visual Tank #2: ❑ Yes ® No Verification method used: visual 6. Is there evidence of the following? Maintenance hole cover is Tank leaks below the Tank leaks above the damaged, cracked, unsecured, or Tank (check if present) designed operating depth designed operating depth appears to be structurally unsound ® Septic/holding Tank #1 ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ® Septic/holding Tank #2 ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Pretreatment Tank ❑ Yes ❑ No ❑ Yes []No ❑ Yes ❑ No ® Pump Tank ❑ Yes ® No ❑ Yes ® No []Yes ® No Describe detail for any "Yes" 7. How many gallons of septage were removed? Tank # 1: 1300 Tank #2: 1300 Pretreatment Tank: Pump Tank: 500 8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other Explanation (Facility name/Site #): Watertown 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: ❑ Troubleshootin and repairs conducted: .❑ Repairs 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 SST.S 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. Company information Employee information Company name: Chip's Septic Services L_ Business license number: 2064 Email: chipseptic@gmail.com Employee's signature: Print name: Pernel Hentges Certification number: (if applicable). 4761 Phone number: 952-200-3176 Date (mm/dd/yyyy): 1/13/2026 www.pca.state.mn.us • 651-296-6300 • 800-657-3864 0 Use your preferred relay service 0 Available in alternative formats wq-wwists4-33 • 10/12/18 Page 2 of 3 Property address: 2630 Fox Street Parcel ID: 0411723420027 City: Orono State: MN Zip code: 55391 Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each 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: Compliangg inN; action form xistMg sv , en w wwist - L1 b This form can be found on the MPCA website at htt s.liv,.1 Nw.Qca.state.mn uj/wgtc. -! ss ts-and-msts-technica,! and-comtsliance-criteria. 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 the inspection report. It represents a third party assessment of SSTS 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. 7082.0700.. subp. 4 Items 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, drywell, 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. ® It does not represent an imminent safety threat by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Company information Company name: Chip's Septic Services Business license number: 2064 ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, 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." Designated Certified Individual (DCI) information Print name: Pernel Hentges Certification number: 4761 1 personally conducted the work described above as a Designated Certified Individual of a Minnesota -licensed SS7S Maintenance Business. I personally conducted the necessary procedures to assess the compliance status of each sewage tank in this SSTS: Designated Certified Individual's signature: Date (mm/dd/yyyy): 1/13/2026 www.pca.stabe.mn.us • 651-296-6300 • 800-657-3864 Use your preferred relay service & Available in alternative formats wq-wwists4-33 • 10112118 Page 3 of 3