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530 Diffley Rd - Septic Maintenance Form 2023-11-06MMINNESOTA POLLUTION CONTROL 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. 7080.2460, 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 affect before February 4, 2008, c) Covers must meet item V above when raised to the ground surface or less than 12 inches from the ground surface. Reporting information Property -owner's address (if different): City: State: Zip code: Phone number: Email address: 1. Did vou measure the accumulation of scum and sludge? j2 -,yes [] No (tank(s) pumped without measuring) 2. Access used to remove septage: 0 Maintenance hole-[2-bther (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? Ates E] No If no, please explain below. Actual Size- Tank#150 C) Tank #2 Tank dump Tank 4. if the owner refuses to allow a Subsurface Sewage Treatment System (SSTS) to be pumped through the maintenance hole, have the ppomplete and sign the following statement, 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 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 fpr the purpose of processing this form. J Owner's signature: V . )"11), -BA&Date (mm/dd/yyyy): AA Aet�� ir www,pca.state.mn,us 651-296-6300 800-657-3864 p Use your preferred relay service Available in alternative formats wq-wwists4-38 - 4128121 Page 2 of 3 Property address: City: State:ti A 5. Is the tank designed as a leaky tank? (Example., seepage pit, cesspool, drywell, leaching pit) Tank #1:,0 Yes n No Verification method used: Tank #2: n Yes n No Verification method used: L1 Parcel ID: Zip code: Is there evidence of tne touowing-f Maintenance hole cover is Tank leaks below the Tank leaks above the damaged, cracked, unsecured, or Tank {check if Present) designed. ope ratio g.depth designed operating depth appears .to be structurally unsound 'Septic/holding Tank #1 El Yes No 0 Yes No --- 0 Yes QNo lic/holding_Tank #2 0 Sep1 0 Yes [] No El Yes t No 0 Yes [] No El Pretreatment Tank El Yes [I No 0Yes Q No El Yes 0 No El Pump Tank El Yes El No 0 Yes 0 No El Yes E] No Describe detail for any "Yes" 7. How many gallons of septagO were removed? Tank #1: , I G_/0 Tank #2: Pretreatment Tank: Pump Tank: 8. Where was the septage taken? 0 Wastewater treatment facility 0 Land application E] 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? rl Yes_oNo If yes, identify tank and explain; 0 Evidence of non-domestic waste 0 Baffle(s) condition n Effluent screen condition El Maintenance hole and extensions condition [3 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: I and conducted, Additional comments or suggestions for owners consideration: U M, 17 M 71 =1 owner. I personally conducted the work described above on behalf of a Minnesota -licensed SETS 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 ❑ As a designated certified individual of the business listed below. By typing/Wgnlng 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: Dike's Septic &McKinley Sewer Business license number: L 1665 & L2899 Email: Employee's signature: www.pca.state.rnn.us • wq-wwists4-38 - 4128121 Employee information 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 • Available In alternative formats Page 2 of 3