1240 Deerwood Dr - Septic Maintenance Form 2022-09-01P
MINNESOTA POLLUTION
CONTROL AGENCY
520 Lafayette Road North maintenance reporting form
VN -35155-41194 Subsurface Sewage
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Doc Type: Compliance and Enforcement
Purpose: Management and maintenance of Subsurface Sewage Treatment Systems (SSTS) are important to ensure resource
protection and long-termand 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 qualifie -a' 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. Page 3 is
Wp-ion 4il r%te r. an ceve-vents.
Sexcure maintenance hovI
e cowse-n-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 Flocked, 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. Ail
screw openings must be refastefIied.
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 (mmlddlyyyy): Reason for maintenance: tCvcy4--
Property address: t>v-., Parcel ID:
City: AM5%" State: M �Aj Zip code: I
Property owners name: 104ia-l-r- VA
Property -owner's address (if different):
City-, State: Zip code:
Phone number: Email address:
1. Did you measure the accumulation of scum and sludge? �t'es Fj No (tank(s) pumped without measuring)
Tan if present)I Percent full
scum Sludge Operating Oppth
I.A. �'� d tar. .1
I rill."
Pf"'Se-Utic1ho inu it ir I
Lj Pretreatment tank
[I Pump tank
2. Access used to remove septage:
Maintenance hole El Other (Unless a ho g tank, go to #4 below)
3. If the maintenance hole was used, were ail covers secured in place? No If 110, please explain below
Actual SizTank# I dank
Size #2 rank #&Pump Tank
4.
If the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance
-h-
refuse to allow the removal of the solids and liquids through the maintenance
(Print owner'& 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 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.
Owner's signature: 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:
C Parcel ID:
City: State:-_ M'vV Zip code:
5. Is the tank dew"ned as a leaky tank? -,(Example: seepage. pit. . cesspool, drywell, leachihqpjt�
_
Tank #1: Yes [I No Verification method used:
Tarek A21 "' 'Yes LD No Verification method used:
8. Is there evidence of the following?
Maintenance hole cover is
Tank leaksbelow the Tank leaks above the damaged, cracked, unsecured, or
Tank,(check if.present) designeA,o-perating depth designed qperating depth appears to be.structurally unsound
E�TSeptic/holding Tank #1 r] Yes El No QYes Ej No fj�eso No
M M Y.,
hlrs
El Septialholding, Tank 92 yes L - j N. 0,
0 Yes N10
Pretreatment Tank ❑ Yes 0 No 0 Yes Q No .0 Yes 0 No
El Pump Tank El Yes El No El Yes El No ❑ Yes ❑ No
Describe detail for any "Yes"
7. How many qaljonsf septage were removed?
Tank #1: Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? Wastewater treatment facility El Land application n Other
% Did yqqj irlp-ratify any npp ks
.�ra r 7 77�901_1 _W,
o y aft cond on w 1 a, -
_s ti�n in th a i�
W _hft- sqw.age
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Yes EYNo If yes, identify tank and explain:
R Evidence of non-domestic waste F-1 Baffle(s) condition F1 Effluent screen condition
0 Maintenance hole and extensions condition 0 Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
`Ex0lan6tion:
1_J t
gnu frno th onfing -an Minnr rannim qrg latod nr ript-finarl by qrnor-,
Troubleshooting and repairs conducted: n Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
r
Pgi*v%p;*%g
"*#1 492 record
I personally conducted the work described above on behalf of a Minnesota licensed SST Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 — 7083:
-ELJ%sA-nqncertjfied-in i.vidtaa
I _who,- has_-r_Jvedl-propor-training,.4ailywock-r
_wiew, 4nd �-periodjcDbservation, Dr
4.
❑
As a designated certified individual of the business listed below.
#�.g mvppm h w- I r. rfify t e- abnvtm. statements to be true, and correct, to the best of my k owledge, and that
py tmv� i
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this inibrmation can be used for the .purpose of processing this form.
Company information Employee infoftat'on j
Company name: Mike's Septic & McKinley Sewer Print name:
'Business'license number: 'Lf -6M&- Certification number: ldappfffca, 616y
Email: dl 411 V Phone number: 952-440-1800
Employee's signature: ,e� fI Date (mm/dd/yyyy):
—.;?-
www.pca,state.mn.us • 651-296-6300 800-657-3864 Use your preferred relay service • Available in alternative formats
Wq-WW1StS4-38 * 4128121 P6065 2 6f 3-