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OCT-17-11 i0 :15 PM MARTY'S EXCA�pTING 612657244� P. 01 <br /> 0 �,o�o �k .�.�C �� �- ��I� � 't6 �6 ; <br /> r ' <br /> Mi�nesota Pollutiun SSTS Aband�nment <br /> ,. ��..M1., � <br /> ��? C:ontrol Agency <br /> ����.,,.iyrttr�laad Nort17 Reporti ri� Form <br /> St,f�a„i,MN ti5155•4194 <br /> 8ubsurtace SewaBe Trealment Systems (SS'�S) Program) <br /> InStructions <br /> Th�s form is offered tu meet thc abandonment requirements o(Minn. R.7080.2500 and Disclosure Requirements pf Minn. Stat. <br /> § 115.55,sut�d_6. Future water SUpply Well placement can also be affected by an abandoned SSTS. <br /> The use of ttiis(urm is not mandatory;however the inFormalion on this form must be submitled to the local governtnent unit(LGU) <br /> within 90 da�is eRer the abandonment.This fotm may be completed by a cerlilied SSTS practitioner or by an indivi�.iu�l who has <br /> direct knawl�idga of how the system was abandoned. <br /> Property Information <br /> Dale of abarrdonment. 10-13-2011 Reason for abandonmcnt� New tenka <br /> '.. _._. .._. .. : <br /> Properiy owrier name(s)- Tony Lund, <br /> Properly owner's address; 360 North arme lane � <br /> C�ty� Oro�to MN. 5536+1.. _.. _ State: ___ _ _ 2ip: <br /> Site addrFss(if ditferent): Same , <br /> City� _ .. State: .._. Z�P' ..; <br /> Complian:te Information <br /> 1. All salid9 and liquids removed from all tanks? � Yes ❑ No <br /> Oispos�i:l Siie� <br /> 2 All el�ctr�cal devices end devices containing mercury removed? ❑Yes � No ' <br /> Disposal Site� Npne <br /> 3. All unde�ground sewage tanks crushed end filled with soit or rock material? �Yes ❑ No or ' <br /> Removed and disposed off site? �Yes ❑ No <br /> Disposa!Sit�: <br /> 4. Conlaminated materials•removed and dispased off sito? ❑Yes �No <br /> Dispctspr Site. None <br /> 5. All underpround cavines••crushed and filled with soil or rock material? �Yes ❑No or: � <br /> Remuvc;d and disposed off site? ❑Yes � No <br /> Dispc�sal SitE: <br /> . . . .. . . . _..... . . . <br /> 6. Fuh�re dlscl�arge to system permanently clen(ed? �Yes ❑No <br /> Metl�ud(;)used: Du.g.up an_fill <br /> •Contam/►wte�l macerlals= Distribution medla,sol(oi sand withln three jeet oj the sys�em bottom, dlstr ibution plpe�,qeatextile <br /> /obric/rosfn poperlstraw, tanks, contomlrra(ed soll o�ound IeaAiny tunks, uny sul(tfwl recF+lved sewo$e <br /> (rom a surface/'oilure(7080,2500 subp.3), <br /> "Unde�sruu�nd cov�tles= Cesspools, leachJng p�ts, drywe(ls,seepage pfrs, vault privles,plt pNvles,pump chmm�Prs; <br /> (7080.15Q0 subp. f). Obes not Inc/ude chamber medla, drop boxes,or distrJDutlon boxes. : <br /> � f <br /> .... . .. ... f <br /> � uw.nu n.s �fwt.J..... .,. . er. �n• i�nw ...... .�.. ��. . . . . _' '-. "-�---' . . ._......... . .. .. . . . . .. ........ <br />