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.401, <br />Minnesota Pollution SSTS Abandonment <br />Control Agency t <br />520 Lafayette Road North Reporting Form <br />St. Paul, MN 55155-4194 <br />Subsurface Sewage Treatment Systems (SSTS) Program) <br />Instructions <br />This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat. <br />§ 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS. <br />The use of this form is not mandatory; however the information on this form must be submitted to the local government unit (LGU) <br />within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has <br />direct knowledge of how the system was abandoned. <br />Property Information <br />Date of abandonment: 9 _z y 1 Reason for abandonment: (I <br />Property owner name(s): ���lfl '��e14 <br />Property owner's address: Q o Wj � 1 N / <br />City: (� B► i )-erf l State: Zip: <br />Site address (if different): <br />City: <br />Compliance Information <br />1. All solids and liquids removed from all tanks? nYes ❑ No <br />Disposal Site: A/f He 3 ! '! &( C- <br />State: <br />2, All electrical devices and devices containing mercury removed? ,Yes ❑ No <br />Disposal Site: <br />I All underground sewage tanks crushed and filled with soil or rock material? Yes ❑ No or <br />Removed and disposed off site? ❑ Yes .a No <br />Disposal Site: 7"'4t1)4- fl a e-,)' <br />4. Contaminated materials* removed and disposed off site? ❑ Yes ® No <br />Disposal Site: f <br />5. All underground cavities** crushed and filled with soil or rock material? R. Yes ❑ No or: <br />Removed and disposed off site? ❑ Yes 2 No <br />Disposal Site: F//!elp <br />6. Future discharge to system permanently denied? ER Yes ❑ No <br />Method(s) used: A"6 ri P <br />Zip: <br />`Contaminated materials = Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile <br />fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks, any soil that received sewage <br />from a surface failure (7080.2500 subp.3). <br />"Underground cavities = Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers <br />(7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes. <br />www.pca.state.mn.us • 651-2%-6300 • 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats <br />wq-wwists4-03 • 11/21/08 Page 1 oft <br />