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��'�E11i��"� <br /> � Minnesota Poilution ` <br /> ���� � SSTS Abandonment <br /> � �:� Control Agency �lili � 3 �016 <br /> 520 Lafayette Road North Re po rti n g Fo rm <br /> St.Paul,MN 55155-4194 C�� �F �R��� <br /> Subsurface ewag�� r tment 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: _ � "� -%� Reason for abandonment: /" �w C -�'•�� i�;�.s �'� ��� �� <br /> � <br /> -- -- � i �� s,c v-�� <br /> Property owner name(s): _ T��.� �%•.f'� <br /> Property owner's address: f t/��- G���,� _ '7'i-i�� f^c�' <br /> — -- <br /> City: G��:._v ------ —.--.._ State: - °�-�� Zip: _ .5�53 9/ <br /> Site address(if different): <br /> City: State: Zip: <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? [�Yes ❑ No <br /> Disposal Site: <br /> 2. All electrical devices and devices containing mercury removed? [�Yes ❑ No <br /> Disposal Site: <br /> 3. All underground sewage tanks crushed and filled with soil or rock material? �Yes ❑ No or <br /> Removed and disposed off site? ❑ Yes ❑ No <br /> Disposal Site: <br /> 4. Contaminated materials'removed and disposed off site? �f Yes ❑ No <br /> Disposal Site: <br /> 5. All underground cavities"*crushed and filled with soil or rock material? ,�]Yes ❑ No or: <br /> Removed and disposed off site? ❑Yes ❑ No <br /> Disposal Site: <br /> 6. Future discharge to system permanently denied? j�']Yes ❑ No <br /> Method(s)used: <br /> 'Contaminated materia(s= Distribution media, soil or sand within three feet of the system bottom, distribution pipes, geotextile <br /> fabriclrosin paperlstraw, tanks, contaminated soi!around leaking tanks, any soil that received sewage <br /> from o surface fai(ure(7080.2500 subp.3). <br /> �'Underground cavities= Cesspools, (eaching pits, drywe((s, 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 • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Availabte in alternative formats <br /> wq-wwists4-03 • 11/21/08 Page 1 of 2 <br />