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Minnesota Pollution SSTS Abandon ment <br /> Control Agency <br /> 520 Lafayette Road North Repo rt ing Fo r m <br /> St.Paul,MN 55155-4194 <br /> Subsurface Sewage Treatment Systems (SSTS) Program) <br /> Instructions <br /> This form is offered to meet the abandonment requirements of Minn. R. 7080.2500 and Disclosure Requirements of Minn. Stat. <br /> § 115.55, subd. 6. Future water supply well placement can also be affected by an abandoned SSTS. <br /> The use of this form is not mandatory; however the information on this form must be submitted to the local government unit(LGU) <br /> within 90 days after the abandonment. This form may be completed by a certified SSTS practitioner or by an individual who has <br /> direct knowledge of how the system was abandoned. <br /> Property Information <br /> Date of abandonment- 5-3-22 Reason for abandonment- Removal of house <br /> Property owner names): City of Ramsey-Aaron Madsen <br /> Property owner's address- 7550 Sunwood Dr. NW <br /> City: Ramsey State- MN Zip- 55303 <br /> Site address (if different): <br /> City: State: zip.. <br /> Compliance Information <br /> 1. All solids and liquids removed from all tanks? El Yes 0 No <br /> Disposal Site: Nelson Sanitation <br /> 2. All electrical devices and devices containing mercury removed? ❑ Yes El No <br /> Disposal Site: None Encountered <br /> 3. All underground sewage tanks crushed and filled with soil or rock material? El Yes [:1 No or <br /> Removed and disposed off site? 7 Yes F] No <br /> Disposal Site: East Central Solid Waste Commission-Mora Landfill <br /> 4. Contaminated materials*removed and disposed off site? F I Yes 0 No <br /> Disposal Site: East Central Solid avast Commission-Mora Landfill <br /> 5. All Underground cavities'crushed and filled with soil or rock material? 7 Yes F-1 No or: <br /> Removed and disposed off site? F-1 Yes F-1 No <br /> Disposal Site: <br /> 6. Future discharge to system permanently denied? FX_1 Yes L1 No <br /> Method(S) used: Permanently Abandonment <br /> *Contaminated materials= Distribution media, soil or sond within three feet of the system bottom, distribution pipes, geotextile <br /> fabric1rosin paperlstraw, tanks, contaminated soil around leaking tanks, any soil that received sewage <br /> from a surface failure (7080.2500 subp.3). <br /> "Underground cavities= Cesspools, leaching pits, drywells, seepage pits, vault privies, pit privies, pump chambers <br /> (7080.2500 subp. 1). Does not include chamber media, drop boxes, or distribution boxes. <br /> www.pca.state.mn.Lis 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 Available in atternative for-mats <br /> wq-wwi-5ts4-03 - 11121108 Page 1 of 2 <br />