3717 Blackhawk Rd - Septic Maintenance Form 2021-01-14MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
(bcpco'Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SSTS) Program
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
protection and long-term and cost-effective sewage treatment. Completion of this form complies with the sewage tank maintenance
requirements under Minn. R. 7080.2450 and 7082.0600. This form may be used to certify the compliance status of the sewage tank
components of the SSTS. This form is not a complete SSTS inspection report, only a tank integrity assessment, and may
only certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional.
Instructions: A copy of this information must be submitted to the system owner within 30 days of the maintenance date and be maintained
by the licensed SSTS maintainer business for a period of five (5) years from the maintenance date. Maintenance reporting to the local unit of
govemment may be required by local ordinance. Check with your local SSTS program for maintenance reporting protocol.
Secure maintenance hole covers
All maintenance hole covers must be returned to service in a sound and durable condition and be capable of withstanding
the anticipated load.
Covers must be re -secured in accordance with Minn. R. 7080.2450, subp. 3, Items C or D:
a) Covers installed under local ordinances adopted after February 4, 2008 must be locked, bolted or screwed or must be 95
pounds in weight. They must be made of material suitable for outdoor use, resistant to ultraviolet degradation and Teaks, and
not susceptible to being slid or flipped. They must have a label warning of hazardous conditions inside the tank. All screw
openings must be refastened.
b) Covers installed under local ordinances adopted before February 4, 2008 must either be buried with at least 12 inches of
soil cover or be secured according to the local ordinance in effect before February 4, 2008.
c) Covers must meet item 'a' above when raised to the ground surface or less than 12 inches from the ground surface.
Reporting information
Date of maintenance (mm/dd/yyyy):
Property address: 31
City: Es7 0,,_
Property`g4ner's name: j f5 S t c - a t t..'_i1
Property -owner's address if different:
City:
Phone number:
Reason f maintenance:
State: ) Zip code:
Parcel ID:
State:
Email address:
Zip code:
1. Did you measure the accumulation of scum and sludge?.'Yes ❑ No (tank(s) pumped without measuring)
Tank (check if present)
Scum
Sludge
Operating depth
Percent full
--ESeptic/holding tank #1
■ Septic/holding tank #2
❑ Pretreatment tank
IN Pump_tank
2. Access used to remove septags„,ErMaintenance hole ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? 1 Yes ❑ No If no, please explain below:
ACTUAL SIZE OF TANKS— TANK#1 f ) ) TANK#2 TANK#3
4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
hole, have them complete and sign the following statement.
, refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's name)
hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and does not fulfill the solids removal requirements of Minn. R. 7080.2450 and 7082.0600.
By typing/signing my name below, 1 certify the above statements to be true and correct, to the best of my knowledge, and
that this information can be used for the purpose of processing this form.
Owner's signature: Date (mm/dd/yyyy):
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Property address:
3-2 fl &
City:
State:
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Parcel ID:
Zip code: j ? % Z Z
Tank #1: ❑ Yes 3 No Verification method used:
Tank #2: 0 Yes 0 No Verification method used:
6. Is there evidence of the following?
Tank (check if present)
Tank leaks below the
designed operatingdepth
Tank Teaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structurally unsound
IIIYes jai No
■ Yes
No
■ Yes �No
'peptic/holding Tank #1
• Septic/holding Tank #2
■ Yes
■ No
■ Yes
■ No
0 Yes
• No
■ Pretreatment Tank
■ Yes
■ No
0 Yes
• No
■ Yes
• No
■ Pump Tank
■ Yes
■ No
IN Yes
■ No
■ Yes
■ No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: /Oda Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? ❑ Wastewater treatment facility 0 Land application ❑ Other
Explanation (Facility name/Site #):
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
0 Yes....-0-No If yes, identify tank and explain:
❑ Evidence of non -domestic waste ❑ Baffle(s) condition 0 Effluent screen condition
❑ Maintenance hole and extensions condition ❑ Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
Explanation:
10. List any troubleshooting and minor repairs completed or declined by owner:
❑ Troubleshooting and repairs conducted: ❑ Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping record
1 personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083:
❑ As a noncertified individual who has received proper training, daily work review, and periodic observation, or
O As a designated certified individual of the business listed below.
By typing/signing my name below, I certify the above statements to be true and correct, to the best of my knowledge, and that
this information can be used for the purpose of processing this form.
Company inform tion
Company name:
Business license number:
Email:
Employee's signature:
1C
Employee information
Print name:
Certification number: (if applicable):
Phone number: VI-10_./a Lac,
Date (mm/ddlyyyy): / / "
www.pca.state.mn.us • 651-296-6300 •
800-657-3864
• Use your preferred relay service • Available in alternative formats
wq-wwists4-38 • 1/7/21 Page 2 of 3