HomeMy WebLinkAboutTank Abandonment 7.1.25Minnesota Pollution SSTS Abandonment
Control Agency
520 Lafayette Road North Reporting Form
St. Paul, 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. Stat.
§ 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 Information
Date of abandonment:`f Reason for abandonment:
ra < < J
Property owner name(s):t
Property owner's address: 4i +o Z.Fi , � �,� l �>� !lr� Ve
City: u #tl State: Zip: �3 S
Site address (if different):
City: .f ; ( V-ev State: Zip:
,Compliance Information
1. All solids and liquids removed from all tanks? T�d- Yes ❑ No
Disposal Site's ,-1
2. All electrical devices and devices containing mercury removed? PM Yes ❑ No
Disposal Site: (Y. e—re-cb- )C4 ( 140 P , (e ':"-e
3. All underground sewage tanks crushed and filled with soil or rock material? Yes ❑ No or
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site: - Vo I L
4. Contaminated materials* removed and disposed off site? ❑ Yes-Q No
Disposal Site: C ver- J & ,
5. All underground cavities** crushed and filled with soil or rock material?pE Yes ❑ No or:
Removed and disposed off site? ❑ Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied?Yes ❑ No
Method(s) used:
'l14L_Gvt1-
Q C C%' i t n t. ,[h a c i
S L Q ✓.
*Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotex1
t! 9'
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage
from a surface failure (7080.2500 subp.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 armat�``��d
wq-wwists4-03 • 11/21/08 Page 1 of 2
fi r .Lll' 1^ 'LO ve- ih0%<
lA i!
a c 3 ✓
Ti o
1 _
r
.I
.v
,1 ■ n
-
■u
I - 11 FI
■ 1
■ ' r
y
F'
.i
•' - ' r5 1
jpI
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.
T North
U
E
E7
fl
I
Certification
1 hereby certify the system was abandoned in a oordance with Minn. R. 7080.2500 and any local requirements.
Name (please print): o A Q Title:
Address: `� U CA;j V1 I U -V-)Y IJ 19AV t
City: J 1� _ State: Zip: 3 S
Phone: i� - 22�' �(7 1 ` License # if pplicable):
Date: t. '-U t 1( Signature:
www.pca.state.mn.us • 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in alternative formats
wq-wwists4-03 • 11121108 Page 2 of 2
ll•.' I
1
- -
1
r
1■
1
N
�
111
■
r
-
I I =