965 Cliff Rd Septic - Maintenance Form Oct 8th 2024NV11ESOTA POLLUTION
J C0 'R00L AGENCY
520 Lafayette Road North
St. Paul, MN 55155-4194
r
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.
Rer)ortine information
Date of maintenz
Property address:
City: e
Property ou(taer's
Property -owner's address (if different):
City:
Phone number:
1
State:
Email address:
Zip code:
Did you measure the accumulation of scum and sludge? ® Yes ❑ No (tank(s) pumped without measuring)
Tank (check if present)
Scum
Sludge
Operating depth
Percent full
Septic/holding tank #1
❑ Septic/holding tank #2
❑ Pretreatment tank
❑ Pump tank
2. Access used to remove septage: ® Maintenance 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:
Tank#1 �1 0 Tank #2 Tank #3 or Pump Tank
u
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.
Owner's signature: Date (mm/dd/yyyy):
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EAGAN
3830 PILOT KNOB ROAD I EAGAN, MN 55122-1810
(651) 675-5675 1 FAX: (651) 675-5694
Plan Submittal: eplans(aDcityofeagan.com
---------------------
For Office Use
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Date Received:
I I
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I Staff: I
-------------------I
SEPTIC SYSTEM MAINTENANCE FORM
Date Pumped: � /-�
# of Tanks Pumped: Total Gallons
Pumped:
A
Site Address: I
T lwl V 55/,-;,
Owner's Name:
Owner's Address (if different from site): ?
Owner's Email: IS ® (� Owner's Phone #: (412
Maintainer's Name:HAR-LIS License Number:
Private Residence: Commercial: Disposal Location: C.",
I- i, e,
Condition of Baffles: q ao,�_ Type of Tanks: Kit LC.,>+ Size of Tanks:
Pumped Through: ) )� is 1," } Effluent Sewage Discharge: Yes: No
Comments:
Name of Person Completing Form:
Date:
You may subscribe to receive an electronic notification from the City of proposed ordinances by signing up for an email update
on the City's website at www.citvofeapan.com/subscribe.
Please submit completed forms to the Building Inspections Division via mail, fax or email.
Properl
City:
Is the tank designed as a leaky tank? (Example: seepage pit, cesspool, drywell, leaching pit)
Tank #1: ❑ Ye
No Verification method used:
Tank #2: ❑ Yes ❑ No Verification method used:
6. Is there evidence of the following?
Parcel ID:
Zip code:
Tank (check if resent)
Tank leaks below the
designed operating _depth
Tank leaks above the
designed operating th
Maintenance hole cover is
damaged, cracked, unsecured, or
appears to be structur I unsound
-Tneptic/holding Tank #1
❑ Yes o
El Yes No
❑ . Ye No
[I Septic/holdingTank #2
❑ Ye ❑ No
❑ Yes ❑ No
❑ Yes [--]No
❑ Pretreatment Tank
❑ Yes ❑ No
❑ Yes [-]No
❑ Yes ❑ No
❑ Pump Tank
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Describe detail for any "Yes"
7. How many gallons of septage were removed?
Tank #1: Tank #2:
Pretreatment Tank:
Pump Tank:
8. Where was the septage taken? ® Wastewater treatment facility ❑ Land application ❑ Other
Explanation (Facility name/Site #): Blue Lake
7
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 ❑ Baffle(s) condition ❑ Effluent screen condition
❑ Maintenance hole and extensions condition ❑ 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:
❑ Troubeeshootinq and repairs conducted: I ❑ Repairs declined by owner:
Additional comments or suggestions for owner's consideration:
Pumping record
/ personally conducted the worts described above on behalf of a Minnesota -licensed SSTS 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/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 Employee mfo�m,�tpp
Company name: Mike's Septic & McKinley Sewer Print name://
Business license number: L 1665 & L2899 Certification number: (if applicable):
Email: //"e Phone number: 952-440-1800
Employee's signature: �_u Date (mm/dd/yyyy):.�
www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats
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