1240 Deerwood Dr - Septic Maintenance Form 2020-09-09Property address: Parcel
City: State: Zip code:
5.
6.
Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, dqwell, leaching pit)
Tank #1- Yes 0 No Verification method used:
Tank #2: 0 Yes F1 No Verification method used:
1-a fhoro avidgknea of +ho fAlletwinn?
Tank (check if resent}
Tank leaks below the
designed opBrat ing dept
Tank leaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
apppars to be structurally unsound
Septic/holding Tank #1
.2*Yes
0 No
QYes ZNo
0 Yes No
0 Septic/holding Tank #2
0 Yes
Q No
El Yes 0 No
Q Yes .0 No
ED Pretreatment Tank
0 Yes
0 No
0 Yes El No
0 Yes 0 No
0 Pump Tank
❑ Yes
[:]No
0 Yes Q No
0Yes El No
Describe detail for any "Yee
7. How many allons of seotane were removed?
J* I
K] Where was the septage taken? 0 Wastewater treatment facility E] Land appli
Explanation (Facility name/Site ft Blue Lake
Did you identify any operational issues or unsafe conditions while assassin
n
Cl
F1 ) condition [] Effluent scree
0
Explanation:
10. List any troubleshooting and minor repairs completed or declined by owner:
Tank # Tank #2: Pretreatment Tank:
Pump Tank:
cation 0 Other
9 the sewage tanks in this system?
Yes No If yes, identify tank and explain:
Evidence of non-domestic waste [I Baffle(s
n condition
Maintenance hole and extensions condition Other conditions (e.g. struct
Additional comments or suggestions for owners consideration:
2ff MIMI=
ral integrity of tank or lid, electrical hazard, etc.)
owner:
I personally conducted the work described above on behalf of a Minnesota licensed SETS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083.,
0 As a noncertified individual who has received proper training, daily work review, and periodic observation, or
n As a designated certified individual of the business listed below.
Company information
Company name* Mikes Septic
Business license number: #1665
Email:
Employees signature:
Employee Information
A 4�'
Print name:
Certification number: (if applicable): N/A
Phone number: 952-440-1800
Date (mm/dd/yyyy):
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wq-wwists438 e 10112118 Page 2 of 3
520 Lafayette Road North
St. Paul, MN 55155-4194
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 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
government 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 leaks, 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 (mmiddlyyyy): -Z0R
Property address:,�� P
City: 0
Property o is name:
for maintenance:�.,6
r� Parcel ID: "
State: Zip code:
Property -owner's address if different
City: State: Zip code:
Phone number: Email address:
1. Did you measure the accumulation of scum and sludge? . Ej Yes ❑ No (tank(s) pumped without measuring)
Tank (check if present) I Scum I Sludge I Operatinq depth I Percent full
Septic/holding tank #1
Septic/holding tank #2
Pretreatment tank
Pump tank
2. Access used to remove septage: ❑ Maintenance holeZ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? ❑ Ye4_.�No If no, please explain below:
� a
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 ownkg name)
hole. I understand that removal of solids and liquids through other access points is not considered a compliant method of
solids removal and d�s not fulfill the s lids remova equirements of Minn. R. 7080.2450 and 7 82.p600.
it
Owner's signatt KCNAN 7 , Date (mm/dd/yyyy):
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service Available in alternative formats
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