HomeMy WebLinkAboutSSTS Abandonment Report ��'�E11i��"�
� Minnesota Poilution `
���� � SSTS Abandonment
� �:� Control Agency �lili � 3 �016
520 Lafayette Road North Re po rti n g Fo rm
St.Paul,MN 55155-4194 C�� �F �R���
Subsurface ewag�� r tment 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: _ � "� -%� Reason for abandonment: /" �w C -�'•�� i�;�.s �'� ��� ��
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Property owner name(s): _ T��.� �%•.f'�
Property owner's address: f t/��- G���,� _ '7'i-i�� f^c�'
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City: G��:._v ------ —.--.._ State: - °�-�� Zip: _ .5�53 9/
Site address(if different):
City: State: Zip:
Compliance Information
1. All solids and liquids removed from all tanks? [�Yes ❑ No
Disposal Site:
2. All electrical devices and devices containing mercury removed? [�Yes ❑ No
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
Disposal Site:
4. Contaminated materials'removed and disposed off site? �f Yes ❑ No
Disposal Site:
5. All underground cavities"*crushed and filled with soil or rock material? ,�]Yes ❑ No or:
Removed and disposed off site? ❑Yes ❑ No
Disposal Site:
6. Future discharge to system permanently denied? j�']Yes ❑ No
Method(s)used:
'Contaminated materia(s= Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile
fabriclrosin paperlstraw, tanks, contaminated soi!around leaking tanks, any soil that received sewage
from o surface fai(ure(7080.2500 subp.3).
�'Underground cavities= Cesspools, (eaching pits, drywe((s, 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 • Availabte in alternative formats
wq-wwists4-03 • 11/21/08 Page 1 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.
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Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name(please print): 1'���'��'� ��►� �7-�( Title:
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Address: a � `� � L�z-�f� •.--- l�'• � °
c�ty: S T ; �l� �c-�-�-�— _�state: �� � z�P: S S-3��
Phone: �/.1. —�'ri`—u:rl. _ License#if applicable): L 3$ j�3
Date: � -�% -/` Signature: ,,��s
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www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-282-5332 or 800-657-3864 Availabte in alternative formats
wq-wwists4-03 • 11/11/08 Page 2 of 1