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904 Lakewood Hills Rd - Septic Maintenance Form 2020-08-03MINNESOTA POLL CONTROL AGEt4C' 520 LAyette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form ftlbsurftee s9wage Treaft"t 4PSWE"a rogram 'I 11 SSTS "I PUM TMa MV DOTMW �and Maird".. anw, -of -sufturk ""sow T'reatt"Wd, Systems (SSTS')'Wb iffiv6ftnt.jb Protection and long-term and cost-effective sewage treatment Completion of this fbffn complies with the sewage M90're resource 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 compi9te SSTS Inspection report and May Only certify sewage tank compliance status when entirely completed and signed on page 3 by a qualified professional. Insftcdons: 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 business0 for a offive ) yoar4 ftM to M*WW" dew mdnww. " ;eporwV to #0 4ocal unit of government may be required by local oidinance. Check with your ur local SSTS program for maintenance reporting protocol I Secure maintenance hole covers X411..maintenance hole zovemmust be returned to 90MIce In aeound and durable and be capable of withstandin the anticipag- lad load. Covers gust be re-96bured in accordance with Minn. 14.71080,24% subp. S, Items C or D: S) 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 Q01 9rdirlan 0 oftct 4014reFebruary 4, 2009. , C) Covers must meet Rern 'a" above when raised to the ground surface or less than 12 inches from the ground surface. Reporting information J*T1 IN - Property -owner's address if different. City. — Phone number: Email address: Did you measure the accumulation of scum and sludge? 2 Yes Tank (check If nrmmnfi I I all—b- tank #2 0 No. (tank(s) Pumped without measuring) fun 2. Access used to remove septqj90.* ATMaintenance hole 0 Other (Unless a holding tank, go to #4 below) 3. If the Maintenance hole was used, were all covers secured in place? ZYes 0 No If no, Please explain below. - ACTUAL SIZE OF TANKS–TANK#I. -.1606 TANK#2.- PUMP TAM . 4. N the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) 0 00. pumped through the maintenance hole, have them Complete and sign the following statement 1, , refuse to allow the removal of the solids and liquids through the maintenance hole. I understand that removal of solids and liquids through otheraccess points is not considered a compliant method of 60ft removal and does nQt WN the gajio& removal MWrernantrw of Mim a. 7080,2460 and 706 2,0600, Owner's signature., Date (mrn/dd/yyyy): www.pca.state.mn.us * 651-296-6300 800-657-3864 w Use your preferred relay service Available in alternative formats wq-W1Wsts4-38 * 10112118 Page 3 of 3 Property -address: -City: 5. k Is the tank designed as a leaky tank? {Example: seepage pit, cesspool, ftwell, leaching pit) Tank #1 * Yes 0 No Verification method used: Tank #2: 0 Yes 0 No Verffication method used: Arl am Were eyluenGe air Tna Ton Tank (check If ppe�eA Tank leaks below the deslgLnied!qp�nq depth Tank leaks above the 0!!�ned poperatingde Maintenance hole cover Is damaged, cracked, unsecured, or as, to be structurally unsound .0septic/holding Tank #1 .,,�es Q No [:]Yes ,, No El Yes afio - 0 Septic/holding Tank #2 0 Yes Q No 0 Yes Q No 0 Yes Q No -0 Pretreatment Tank 0 Yes E] No OYes ONo No -0 Pump Tank 0 Yes .0 No O_Yes [ No 0 Yes []No Describe detail fbr any aYes7 7. Now many gallons of septage were removed? Tank #1: / 0, 0 6 Tank 8. Where was the Mage taken? 19 Wastr treat Explanation (Facility name/Site #): 7 El 'Pretreatment Tank-. pump Tank: facility 0 Land application 0 Other Did you Identify any operational issues or un&We conditions while assessing the sewage tanks In this system? 0 Yes No If yes, identify tank and explain: 0 Evidence of non-domestic waste 0 BMWs) condition 0 Effluent screen condition 0 Maintenance hole and extensions condition 0 Other Conditions (e.g. structural lategrity of tank or lid, electrical hazard, etc.) Explanation: 1-0. Ust anytroubleshooting and minor repairs complefto or declined by owner., Additional comments or suggestions ibr owners iconsideradon: Pumping record I P=r naftYCwducW Me we des bed abs on behaff-of a Wmesola4kensed SSTS Mairgenance Business, in compliance with Minnesota Rules Chapters 7080 - 7083 0 As ah'briteftiff6d intlMdual who has received proW Veining, drily wo* review, and periodic observation, Or El As a designated certified individual of the business fisted below. Company Information Employee information Company name: Mikes Septic Business license number: #1665 Email: Print name: Certification number: (if applIeWe): N/A Phone number. 952A40-1800 Date�mmkkvyyyy): www.m.state.mmus * 651-296-6300 800-657-3864 Use your preferred relay service Available In alternative formats wq-wwists4-38 * 10112118 Page 2 of 3