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):
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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
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