550 Lone Oak Rd - Septic Maintenance Form 2023-12-26 MUNNESOTA POLLUTION Sewage tank
CONTROL AGENCY
520 Lafayette Road North maintenance reporting form
St.Paul,MN 55155-4194 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(6)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 Sinmiddlyyyy): 12 — Za—:2 3 Reason for maintenance:
Property address:
City- State: Zip code:
!y4a
Property dwAer's name: Ar%'r-C1,0
Property-owners address(if different):
City: State: Zip code:
Phone number: Email address:
1. Did you measure the accumulation of scum and sludge? IN Yes Cl No(tank(s)pumped without measuring}
Tank(check if present) Scum Sludge, Operating depth Percent full
- "Septic/holding tank#1 7/4 '
[j Septic/holding..tante#2
[] Pretreatment tank
Pum tank
2. Access used to remove septage:--43-Maintenance hole [I Other(Unless a holding tank,go to#4 below)
3. If the maintenance hole was used,were all covers secured in place? 4n-1 Yes [3 No If no,please explain below:
Tank#1 j Tank#2 Tank#31Pump 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.
1, , 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.
f3y 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:- . Date(mm/dd/yyyy):
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Property addr ss: csso_ Lile , C-,Z-k Parcel ID:
city: State: Zip code:
S. Is the tank designed as a leaky tank?(Example:seepage pit,cesspool,ftwell,leaching pit)
Tank#1: El Yes Od No Verification method used:
Tank#2: []Yes,,&No Verification method used:
6. Is there evidence of the following? Maintenance hole cover Is
Tank leaks below the Tank leaks above the damaged,cracked,unsecured,or
Tank(check if present) designed operating depth designed operating depth appears to be structurally unsound
eptic/holding Tank#1 n Yes, No Yes Z No ❑Yes ZNo
E]Septic/holding Tank#2 0 Yes M_ No El Yes [-]No 0 Yes—El No
E]Pretreatment Tank E]Yes 0 No [:]Yes ❑No 0 Yes 0 No
Pump Tank Yes Z No 0 Yes RNo ❑Yes-Z No
Describe detail for any"Yes"
7. How many gallons of septage were removed?
Tank#1: IS6-6 Tank#2: Pretreatment Tank: ^ Pump Tank: S 0 0
8. Where was the septage taken?10 Wastewater treatment facility C1 Land application El Other
Explanation(Facility name/Site ft Blue Lake
9. Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system?
rl Yes No If yes,identify tank and explain:
0 Evidence of non-domestic waste El Saffie(s)condition El Effluent screen condition
[]Maintenance hole and extensions condition M 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:
El Troubleshooting and repairs conducted: El epairs declined Py owner:
Additional comments or suggestions for owner's consideration:
Pumping record
I personally conducted the work described above on behalf of a Minnesota-licensed SSTS Maintenance Business,in compliance
with Minnesota Rules Chapters 7080—7083.,
N As a noncertified individual who has received proper training,daily work review,and periodic observation,or
R 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 information
Company name: Mike's Septic&McKinley Sewer Print name:
Business license number, L 1665&L2899 Certification number:(if applicable):
Email:
Phone number: 952-4401800
Employee's signature: Date(mm/dd/yyyy)
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