1240 Deerwood Dr - Septic Maintenance Form 2021-05-07WNHESOTA POLLUTION
OM AGENCY
AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
camirarve tank
4, VV
m;kintPn;;nrP report no form
-Subsurface -Sewage
Treatment Systems (SSTS) Program
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
prote on aHyl long-term and cost-effective sewage treatment. Como efion of this form complies with the sewage tank maintenance
requirements under Minn. R. 7080.2460 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.
Irtstructionw. 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 SST S maintainer business for a period of five (6) 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.
-Secu,r,,e,,mali,nt--.ena,nc,e,hole,-over-s
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
i ! I- A n^f%o
soii cover or be secured IoGal 0 ` nal -IG& in effe bc-'Iure - -- r1jary
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C) covers must meet item V above when raised to the ground surface or less than 12 inches from the ground surface.
Reporting information
Date of maintenance (mm/dftyyy): —3-,-ZJReason for maintenance:
Property address: Parcel ID:
City: i Slate: Zip code:
90-operty ^%Fn;110 nomel.
y
Property -owner's address if different
City: State: Zip code:
Phone number Email address:
T. Didyou measure the accumulation of scum and sludge? -�es 'Li No (tank(s) pumped without measuring)
'r a *6 1
ank ,olhaclk 11, pro-sep"11, depth
1 Part-ont hill
...-aZeptic/holding tank. #1 A
U Septic/holding tank #2
0 Pretreatment tank
PUMn tank
99� - M RA..;
i. Ac^cs^ wacd #.ft —,1e,,LA0ther (Unless a holdi. g. tank, go to #4 beloitl
3. If the maintenance hole was used, were all covert secured in place? 0 Yes If no, please explain bei
ACTUAL SIZE OF TANKS~ TANK# TANX#9-- PUMP TANK#j_
V V
4. If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the m iii
Itetance
hole, have them complete i1nd sign the following statement.
I , , refuse to allow the removal of the solids and liquids through the maintenance
k v
(Print ovu�ier s e}
hole. I underttand 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 typing1signing my n.ame below, I �OKqthe above statements to be true and correct, to the best of my knowledge, and
that this information can b% used for tri purpose of processing this form.
Owner's signature -t- Date (mm/dd/yyyy):
www.pca.state.mn.us • 651-296-6300 900-657-3864 • Use your preferred relay service Available in alternative formats
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Property address:
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hi
14
State:
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IL" UV%-A1V"1W%j 00 0 W JMY 4"1111%ii I L-AgAtllpff�
Tank #Ues 0 No Verification method used:
Tank #2:— —
U. YesU No Verification method used:
Is thara evid6nca of tha folloiWina?
I Tank #1
i Tank #2
0+Menf Ttinle
I I Pretreat, if, ra, e*%
tj
0 Pump Tank
Describe detail for any "Yes -
Tank leaks below the
No
XM=34�N2
Yes No
Yes ❑ No
now many gallons of septage were removed?
Tank #1: Tank #2:
Where was the septage taken? 0
s
Wrater
ff—"p1-t-Fat-jiity-naI me/W,e
I Tank leaks above the
i I designed uperatinu dej
Yes, LQWo
Yes No
17-1 yes
t-, 1-j No
OYes 0 No
Pretreatment Tank:
Zip code:
Maintenance hole cover is
damaged, cracked, unsecured, or
itii�ato %- - US---tv.
tKuyLuldify urlsoi,ifii
0 Yes No
U.yes u NO
yea. M Kirt
aar
L1 Yes L1 No
Pump Tank:
treatment facility El Land application 0 Other
9. Did You identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
10 ifireide
s, i ritify tank and explaim
,y -
Evidence of nor -domestlic- waste 0 Baa 'luta) condlition M Fffltjontfirxtawn rzridition
0 Maintenance hole and extensions condition 0 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:
I rervn* %f 0 R Irs de, inet
r-1 Tro-b eelloolfi-ng and Ire conefut "eel:
L -j it W -A r a4 %0410
1 .# a Rw ee W- - - I - .4 bv, ovv n e r.
Additional comments or suggestions for owner's consideration:
Pumping record
1personally conducted the work desodbed above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 - 7083
1-104-1.&M—A —A
A. *-1 AI
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Irseasv ertir%rao1L111=u iIou.vluuaIfWV II ary robsmann,
O-As-a.desigiiatedv-certilied, individual -of the, business, listed., below.
By typing1signing 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 Infonnation
Company name: Mike's Septic & McKinley Sewer
Ri mintasc limnse- number- L161315 12899
Email:
Empioyee's signature:
Employee information
Print name:
Certification number: (if -applicable):
Phone number, 962-440-1800
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www.pca.state.mn.us 0 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats
wq-Ww1s&4-38 - J/W21 Page 2 of 3