HomeMy WebLinkAboutSSTS Abandonment Report �.� .
�� Minnesota Pollution SSTS Abandonment
Control Agency
520 lafayette Road North Re p o rt i n g Fo r m
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 pfacement can also be affected by an abandoned SSTS.
The use of this fortn is not mandatory;however the information on this foRn must be submitted to the local govemment unit(LGU)
within 90 days aRer the abandortment.This fortn may be completed by a certified SSTS practitioner or by an individual who has
direct knowtedge of how the system was abandoned.
Property Information
Date of abandonment: `'Z"U ' � � Reason for abandonment:
Property owner name(s):
Property owner's address:
City: �� State: �..�� Zip:
Site address(if different):
City: State: Zip:
Compliance Information
1. All solids and liquids removed from all tanks? �$Yes ❑No
Disposal Site:
2. All elecUical devices and devices containing mercury removed? ❑Yes ❑No N/A
Disposal Site:
3. All underground sewage tanks crushed and filled with soil or rock material? �Yes ❑ No or
Removed and disposed off site? ❑Yes �No
Disposat Site:
4. Contaminated materials'removed and disposed off site? (�Yes ❑No
Disposal Site:
5. All underground cavides"cnished and filled with soil or rock material7 �Yes ❑No or.
Removed and disposed off site? ❑Yes �No
Disposal Site:
6. Future discharge to system permanently denied? �Yes ❑No
Method(s)used:
•Contaminated moterlals= Dtstributlon medlo,soll or sand withfn three feet of the system bottom,dlstributlon pfpes,geotextile
febrtc/rasin paper/strew, tonks,contominoted soll around leaking tanks,arry so11 that received sewage
from a surface fo!lure(7080.2500 subp.3).
•'Urtdergrourtd covltles e Cesspools, leaching pfu,drywel(s,seepage plu, vault priv�es,p�t prlvies,pump chombers
(7080.2500 subp. 1). Does not fnc(ude chamber medla,drop boxes,or d�stributfai boxes.
www.pca.state.mn.us • 651-296-6300 • 800•657-3864 • TTY 651-282-5332 or 800-657•3864 • Available in altemative formats
wq-wwfsts4-03 • 11/21l08 Poge 1 of 2
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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.
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Certification
1 hereby ceriify the system was abandoned i accordance with Minn.R. 7080.2500 and any! al r�quirements.
Name(please p�nt): Glen Kothrade �� �(►�, ,� TUe: President ����yn�
Address: 12059 Whitetail Ln
�;ty; Hanover g�te; MN Z;p: 55341
Phone: 763.498.8702 l.icense#if applicable): ��92
Date: �Z—�t— 1 lP Signature: �� -'�G Sc�Q �'
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www.pca.state.mn.us • 651•296-6300 • 800-657-3864 • TTY 651-282-5332 or 800•657-3864 • Available in altemative formats
wq-wwlsts4-03 • i!l21/08 Page 2 of 2