550 Lone Oak Rd - Septic Maintenance Form 2021-09-03MINNESOTA POLLUTION
CONTROL AGENCY Sewage tank
520 Lafayette Road North'Z m a i n to n a n o r
St. Paul, MN 55755-4194 SEP Q3 a eporting form
20,1 Subsurface Sewage
Treatment Systems (SETS) Program
Doc Type: Compliance and Enforcement
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, 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.
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
optional and not required to be completed on routine maintenance events.
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 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 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 qm/d `"7 `
c( �--° d13►�►1+yD� P �- • eason for maintenance:
Propertjaddress: Parcel ID:
City: State: /' Zip code:
rropenrowners name: _
Property -owner's address (if
City:
Phone number:
State:
Email address:
Zip code:
1. Did you measure the accumulation of scum and sludgeZ_AET-Yes ❑ No (tank(s) pumped without measuring)
7 aink (check if resent) Scum Slud e Operating depth Percent full
®-Se
fic/holdinn tank #1
❑
Septic/holding Septic/holdingtank #2 e. ,
❑ Pretreatment tank
.-Pum tank !
2. Access used to remove septage`j_,,0'Maintenance hole ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? es ❑ No If no, please explain below:
Actual Size- Tank#i ` f +f -,Tank #2 Tank #3/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.
I fPrmt owner's -name) , refuse to allow the removal of the solids and liquids through the maintenance
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 typing/signing 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:
www.pca.state.mn.us 651-296-6300 • 800-657-3864
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Date (mm/dd/yyyy):
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Property address:
I k-1, C )DI
City: State:
5. Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywall, leaching pit)
Tank #1: 0 Yes 4Z No Verification method used:
Tank 2: nYes --allo Verification method used:
6. Is there evidence of the following?
Parcel ID:
Zip code:
Tank (check if present)
Tank leaks below the
designed operatingdepth
Tank leaks above the
designed op!!rating depth
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structurally unsound
12teptic/holding Tank #1
0 Yes 121'No
Q Yes Qjb
Yes'Ef No
0 Septic/holding Tank #2
0 Yes 0 No
0 Yes 0 No
0 Yes O' No
0 Pretreatment Tank
Q Yes, 0 No
Ll Yes Q No
0 Yes 0 No
,2rPump Tank
0 Yes -ofl-No
1 0 Yes EJ No
[I Yes ,`No
Descjibe detail for any "Yes"
7. How many gallon's of septage were removed?
Tank #1: Tank #2- Pretreatment Tank*-, Pump Tank:
8. Where was the septagetaken? 10 Wastewater treatment facility [I Land application Q Other
Explanation (Facility name/Site ft Blue Lake
9. Did you identify any aperaflonat issues or unsafe conditions while assessing thesewage tanks in, this system?
C3 Ye;,�No If yes, identify tank and explain:
0 Evidence of non-domestic waste [3 Baffle(s) condition E] Effluent screen condition
0 Maintenance hole and extensions condition n Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.)
Explanation:
10. List any troubleshooting and minor repalfs, completed ordectined by wwn"-.,
0 Troubleshooting and repairs conducted: I [I Repairs declined by owner:
Addiffin-nal comments w suoeash-ons for owner's consideration-,
I personally conducted the work described above on behalf of a Minnesota -licensed SSTS Maintenance Business, in compliance
with Minnesota Rules Chapters 7080 - 7083:
0 As a noncertified individual who has received proper training, daily work review, and periodic observation, or
[I As a designated certified 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 information Employee informatIORA
A A I
,
IVI
Company name: Mike's Septic & McKinley Sewer Print name. k
Business license number: L 1665 & L2899 Certification number: (if applicable):
Emait Phone nurnber: 02-4-410-180nG
Employee's signature: Date (mmlddlyyyy):
www.pca.state.mn.us • 6SI-296-6300 800-657-3864 • Use your preferred relay service Available in alternative formats
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