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1240 Deerwood Dr - Septic Maintenance Form 2024-10-25AHNHESOTA POU CONTPROL AGENCY 520 Lafayette Road North St. Paul, MN 55155-4194 Sewage tank maintenance reporting form Subsurface Sewage Treatment Systems (SSTS) Program ,poc 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. Completionof this form complies with the sewage tank maintenance requirements under Minn. R- 7080.2450 and 7082.0600. This form may be used to certity the compliance status of the sewage tank complete SSTS inspection report, on ryycomponents of the SSTS. This form is not a comP nd signed page 3 by a qualified professional. only certify sewage tank compliance status when entirely completed a instructions: A copy 0 . f 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 maintenanmaintenance date. Mainptenanetreprotocolporting to Page 3 is the local unit of government may be required by local ordinance. Check with your local SSTS program for ce terra 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. n. R. 7080.2450, subp. 3, items C or D: Covers must be re -secured in accordance with Min a) Covers installed under local ordinances adopted after February 4, 2008 must be looked, 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 V above when raised to the ground surface or less than 12 inches from the ground surface. Reporting information Date of maintenance (mmIddlyYYYY 1012512024 Reason for maintenance: Routine Property address: 1240 Deerwood Dr Parcel ID: City; IGH State: MN Zip code: 55077 Property owner's name: Mark Baoust Property -owner's address (if different): City: Phone number: State: Email address: Zip code: 1. Did you measure the accumulation Of scum and sludge? 0 Yes 0 No (tank(S) pumped without measuring) Tank #1 #2 Scum Percent full 2. Access used to remove SOPW99: 0 Maintenance hole C] Other (Unless a holding tank, go to #4 below) 3. If the maintenance hole was used, were all covers secured in place? 0 Yes [] No If no, please explain below. Tank#1 1000 Tank #2 Tank #3 or 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. 11 , refuse to allow the removal of the solids and liquids through the maintenance (Print owner's name) other hole. I understand that removal of solids and liquids throughaccess points is not considered abompliant 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 (mmldd/yyyy): wWw,pca.state.mn-us 6S1-296-63©0 800-657-3864 Use your preferred relay service wq-wwists4-38 0 4128121 Available in alternative formats Page I of 3 Property address: City: IGH RP l')An naimrwnnd Dr State: MN Is the tank designed as a leaky tank? (Example: seepage Pit, cesspool, drywell, leaching Pit) Tank #1: (0 Yes El No Verification method used: Tank #2: n Yes [I No Verification method used'. 6. is there evidence of the following? I N R 9. Tank (check if present). 0 Septic/holding, Tank 0 Septic/holding Tank #2 0 pretreatment Tank 0 Pump. Tank .. _ Describe detail for any "Yes" Tank leaks below the Tank leaks above the Yes El No ❑ yes E] No. Yes No ❑Yes. 0 No Yes Q No 0 Yes 0 No Yes n No 0 Yes 0 Yes Q No Parcel ID: Zip code: 55077 Maintenance hole cover Is damaged, cracked, unsecured, or appears to be structurally unsound ❑ Yes ONO El Yes 0 No []Yes.., 0 No... nYes 0 No How many gallons of septage were removed? Pretreatment Tank: Pump Tank: Tank #1: 1000 Tank #2: Where was the septage taken? [D wastewater treatment facility 0 Land application 0 Other Explanation (Facility name/Site #): Blue Lake Did you identify any operational issues or unsafe conditions while assessing the sewage tanks in this system? n Yes Z NO If yes, identify tank and explain: ❑ Evidence of non -domestic waste [I Baffle(s) condition n Effluent screen condition Maintenance hole and extensions condition [I Other conditions (e.g. structural integrity of tank or lid, electrical hazard, etc.) V—AIJ 0"0;1W1 la - 10. List any troubleshooting and minor repairs completed or declined by owner: Repairs decline �b n Troubleshoo ijjj�aa�nre airs conduc�te& Additional comments or suggestions for owner's consideration: owner: 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: R As a noncertified individual who has received proper training, daily work review, and periodic observation, or El 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 &.. McKinley ,Sewer Business license number* L 1665 & L2899 Email, Employee's signature: Cody McKinley Employee information Print name: Cody McKinley.... Certification number: (if applicable): Phone number: 952-440-1800 Date (mm/dd/yyyy), 10/25/20,24 Available in alternative formats WWW,pCa.state.Mn-US 6651-296-6300 800-657-3864 Use your preferred relay service page 2 of 3 wq-wwists4-38 - 4128121