1240 Deerwood Dr - Septic Maintenance Form 2023-08-23tA- INNESOTA POLLUTION
C094TROL AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
Sewage tank
maintenance reporting form
Subsurface Sewage
Treatment Systems (SSTS) 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 (mmiddlyyyy): --
Property address: I L,16
City:�C C
Property o er's name: i
Property -owner's address (if different):
City:
Phone number:
1.
for maintenance:
A Zip code:
State: _
Email address:
Zip code:
naa .,.,,, ...annoim tha accumulation of scum and sludge? _L Yes ❑ No (tank(s) pumped without measuring)
2. Access used to remove septage:_,aMaintenance hole ❑ Other (Unless a holding tank, go to #4 below)
3. If the maintenance hole was used, were all covers secured in place? yes []No If no, please explain below.
Actual Size- Tank#11C)OO 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 , refuse to allow the removal of the solids and liquids through the maintenance
(Print owner's 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 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.
Owners signature: Date (mm/dd/yyyy):
www.pca.state.mn.us • 651-296-6300 0 800-657-3864 Use your preferred relay service Available in alternative formats
wq-wwists4.38 • 4/28/21 Page 1 of 3
Proper" address: t
City:
S.
Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1:/ff Yes 0 No Verification method used:
Tank #2: 0 Yes 0 No Verification method used:
S. Is there evidence of the following?
Parcel ID:
Zip code:
Tank check If present)
Tank leaks below the
designed operating depLh,
Tank leaks above the
designed operating de
Maintenance hole cover is
damaged, cracked, unsecured, or
app ars to be structurally unsound
en Seplic/holding Tank #10,Z�No
yes
El No
El YesENO
❑yes
El Septic/holding Tank #2
0 Yes
0 No
0 Yes 0 No
0 Yes Q No
0 Pretreatment Tank
El Yes
[3 No
QYes Q No
Q Yes 0 No
E] Pump Tank
0 Yes
0 No
0 Yes [3 No
D Yes El No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: 1 0()o Tank #2:
Pretreatment Tank:
Pump Tank:
8. Where was the septage, taken? 0 Wastewater treatment facility n Land application 0 Other
Explanation (Facility name/Site #): Blue Lake
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
Yes No If yes, identify tank and explain:
Evidence of non-domestic waste [j Baffie(s) condition 0 Effluent screen condition
Maintenance hole and extensions condition 0 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:
conducted:
Additional comments or suggestions for owner's consideration:
1 1 11 F 1. 41
declined by owner:
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
0 As a designated certified individual of the business listed below.
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.
Company Information
Company name: Mike's Septic & McKirilpy Sewer
Business license number: L 1665 & L2899
Email:
Employee's signature:
www.pca.state.mn.us
wq-ww1sts4-38 * 4128121
Employee In o lion
Print name:
Certification number: (if applicable):
Phone number: 952-440-1800
Date (mm/dd/yyyy):.
& 651-296-6300 800-657-3864 - use your preferred relay service 0 Available in alternative formats
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