530 Diffley Rd - Septic Maintenance Form 2020-11-12cn
MINNESOTA POLLUTION
t' CONTROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
,elotfik)
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 ordnance. 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 waming 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 (mmickUyyyy
Property address:
City:
Property ner's name:
2_ az
•ley a
Reason for maintenance:
11'ok1 ydejr
State:
11/4i
Parcel ID:
Zip code:
Property -owner's address if diffetent
City:
Phone number:
State:
Email address:
1. Did you measure the accumulation of scum and sludge?
Zip code:
Yes 0 No (tank(s) pumped without measuring)
Tank (check if present)
•Scum
Sludge
Operating depth
Percent full
....Er Septic/holding tank #1
0 C., c\ ,
7 A
0 Septic/holding tank #2
0 Pretreatment tank
0 Pump tank
2. Access used to remove septage: they (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? 0 Yes .-'No If no, please explain below:
ACTUAL SIZE OF TANKS—TANK#1: CV() TANK#2: PUMP TANK
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.
3rVd1, p4e1 e.c , refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's nante)
hole. 1 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.
Owner's signature:
www,pca.state.mn.us • 651-296-6300 • 800-657-3864
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Date (mmidd/yyyy): a- -2-a
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Peige I of
• Property address:
City: State:
5. Is the tank designed as a leaky tank? (Example: seepage pit cesspool, drywell, leaching pit)
6.
Tank #1:
Tank
Verification method used:
Verification method used:
•
Parcel ID:
Zip code:
n
Is mere eviaence OT me rouowmg-e
Tank (check if present)
Tank leaks below the
designed operating depth
Tank leaks above the
designed operating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structurally unsound
—Septic/holding Tank #1
El Septic/holding Tank #2
J2Yes El No
El Ye
El Yes
0 Yes El No
0 Yes El No
0 Yes E
No
El Pretreatment Tank
0 Yes El No
0 Yes El No
0 Yes 0 No
0 Pump Tank
El Yes El No
El Yes El No
0 Yes 0 No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: 1,1 Tank #2: Pretreatment Tank: Pump Tank:
8. Where was the septage taken? Wastew r tjeatment facility 0 Land application 0 Other
Explanation (Facility name/Site #):
9. Did you identify any operational issues or unsafe conditions white assessing the sewage tanks in this system?
El Yes No If yes, identify tank and explain:
El Evidence of non -domestic waste El Baffle(s) condition El Effluent screen condition
0 Maintenance hole and extensions condition El 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:
0 Troubleshooting and repairs conducted: 0 Repairs declined by owner
Additional comments or suggestions for owners 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
0 As a designated certified individual of the business listed below.
Company information •Employee information
Company name: Mike's Septic Print name:
Business license number: #1665
Email:
Employee's signature:
Certification number: (if applicable): NIA
Phone number: 952-440-1800
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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