Laserfiche WebLink
M1 MINNESOTA POLLUTION <br />CONTROL AGENCY <br />520 Lafayette Road North <br />St. Paul, MN 55155-4194 <br />Sewage tank <br />maintenance reporting form <br />Subsurface Sewage <br />Treatment Systems (SSTS) Program <br />Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource <br />protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance <br />requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank <br />components of the SSTS. This form is not a complete SSTS inspection report and may only certify sewage tank compliance <br />status when entirely completed and signed on page 3 by a qualified professional. <br />Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained <br />by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of <br />government may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol. <br />Secure maintenance hole covers <br />All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding <br />the anticipated load. <br />Covers must be re-secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D: <br />a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95 <br />pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and leaks, and <br />not susceptible to being slid or flipped. They must have a label warning of hazardous conditions inside the tank. All screw <br />openings must be refastened. <br />b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of <br />soil cover or be secured according to the local ordinance in effect before February 4, 2008. <br />c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface. <br />Reporting information <br />Date of maintenance (mrnicid/yyyy): C3/62/ZZO <br />Property address: <br />City: Orono <br />2700 White Oak Circle <br />Property owner's name: Robert Knuth <br />Property-owner's address if different: <br />City: <br />Phone number: 316-648-9328 <br />Reason for maintenance: Compliance Inspection <br />Parcel ID: 0411723420021 <br />State: MN Zip code: 55356 <br />State: <br />Email address: <br />I. Did you measure the accumulation of scum and sludge? El Yes <br />Zip code: <br />Z No (tank(s) pumped without measuring) <br />Tank (check if present) Scum Sludge Operating depth Percent full <br />MI Septic/holding tank #1 <br />1:3 Septic/holding tank #2 <br />II Pretreatment tank <br />• Pump tank <br />2. Access used to remove septage: 31 Maintenance hole ID Other (Unless a holding tank, go to #4 below) <br />3. If the maintenance hole was used, were all covers secured in place? 0 Yes Z No If no, please explain below: <br />Septic tank covers have over 12 inches of soil over them. Manhole cover was a plastic cover that was used to replace the <br />concrete manhole. Cannot support the weight of the soil over it. Ground water can seep through lids as they are just used as <br />covering.. <br />4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance <br />hole, have them complete and sign the following statement. <br /> , refuse to allow the removal of the solids and liquids through the maintenance <br />(Print owner's name) <br />hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of <br />solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600. <br />Owner's signature: Date (mm/del/yyyy): <br />www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats <br />wq-wwists4-38 • 10/12/18 Page 1 of 3