HomeMy WebLinkAbout2015-12-14 SSTS Abandonment Report 62.t\ coei • TO ov w
V, Minnesota Pollution
Control Agency SSTS Abandonment
520 Lafayette Road North Reporting Form
St_Paul,MN 55155-4194
Subsurface Sewage Treatment Systems (SSTS) Program)
Instructions
This form is offered to meet the abandonment requirements of Minn. R.7080.2500 and Disclosure Requirements of Minn.Stat.
§ 115.55,subd.6. Future water supply well placement can also be affected by an abandoned SSTS.
The use of this form is not mandatory; however the information on this form must be submitted to the local government unit(LGU)
within 90 days after the abandonment.This form may be completed by a certified SSTS practitioner or by an individual who has
direct knowledge of how the system was abandoned.
Property Information
Date of abandonment: 12-14-15 Reason for abandonment: House was demolished and was also previously hooked
Up to city sewer.
Property owner name(s): City of Oak Park Heights
Property owner's address: 14168 Oak Park Blvd N.
City: Oak Park Heights State: MN Zip: 55082
Site address(if different): 6180 Osgood Ave N.
City: Oak Park Heights State: MN Zip: 55082
Compliance Information
1. All solids and liquids removed from all tanks? ® Yes 0 No
Disposal Site: Pinkys Sewer and Enviromental Service.
2. All electrical devices and devices containing mercury removed? ®Yes 0 No
Disposal Site:
3. All underground sewage tanks crushed and filled with soil or rock material? Yes 0 No or
Removed and disposed off site? 0 Yes ® No
Disposal Site:
4. Contaminated materials*removed and disposed off site? ®Yes 0 No
Disposal Site: Pinkys Enviromental and Sewer service.
5. All underground cavities**crushed and filled with soil or rock material? ®Yes 0 No or:
Removed and disposed off site? 0 Yes ® No
Disposal Site:
6. Future discharge to system permanently denied? ®Yes 0 No
Method(s)used:
*Contaminated materials= Distribution media,soil or sand within three feet of the system bottom,distribution pipes,geotextile
fabric/rosin paper/straw, tanks, contaminated soil around leaking tanks,any soil that received sewage
from a surface failure(7080.2500 subp.3).
**Underground cavities= Cesspools, leaching pits,drywells,seepage pits,vault privies,pit privies,pump chambers
(7080.2500 subp. 1). Does not include chamber media,drop boxes,or distribution boxes.
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11/21/08 Page 1 of 2
Map
Include location of building sewer, septic tank(s), soil dispersal system, cesspools, seepage pits, and other pits. Also
include a permanent reference point(s) and dimensions.
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Certification
I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements.
Name(please print): Jon Bell, Bell's Trucking INC. Title: President
Address: P.O Box 775
City: Stillwater State: MN Zip: 55082
Phone: 651.439.6375 License#if applicable): L2406
Date: 1-12-16 Signature: 91.4. aRAt
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats
wq-wwists4-03 • 11/21/08 Page 2 of 2