2022 - Annual Storm Water Comprehensive Site Evaluation

• Site conducted

  Select

• Conducted on

  Media

• Prepared by

• Location
  Address

SWPPP and Record Review

• 1. Is a copy of the storm water permit located on-site?

  Yes

  No

  N/A

• 2. Is a copy of the Storm Water Pollution Prevention Plan (SWPPP) located on-site?

  Yes

  No

  N/A

• 3. Is the SWPPP up-to-date? (Note areas which need to be updated.)

  Yes

  No

  N/A

• 4. Has annual employee training been conducted and documented?

  Yes

  No

  N/A

• 5. Are inspections before performed and documented according to SWPPP frequency?

  Yes

  No

  N/A

• 6. Does the site discharge storm water?

  Yes

  No

  N/A

• 7. Have appropriate storm water samples been collected?

  Yes

  No

  N/A

Field Inspection Findings

• 8. Are Best Management Practices (BMP's) / erosion and sediment controls noted in the SWPPP being followed?

  Yes

  No

  N/A

• 9. Is the site maintenance in an orderly manner to prevent storm water pollution?

  Yes

  No

  N/A

• 10. Fuel/Oil Storage Area: Is the area free of leaks and spills?

  Yes

  No

  N/A

• 11. Are buckets used to catch oil or other containers covered and/or not exposed to the weather?

  Yes

  No

  N/A

• 12. Are storm water discharge locations (outfalls) free of visible silt or other contaminants?

  Yes

  No

  N/A

• 13. Was there a storm water discharge the day of the inspection? If yes, was there evidence of turbidity, sediment or oil in the discharge?

  Yes

  No

  N/A

• 14. Is there non-storm water discharges (water pumped off-site)

  Yes

  No

  N/A

• 15. Are the roads free of visible trackout from the facility?

  Yes

  No

  N/A

• 16. Is the property and surrounding ditches free of trash and litter?

  Yes

  No

  N/A

• 17. Is the property perimeter in good condition? (No erosion off site. No stock piled material off site. Storm water runoff only leaving property at permitted outfall.)

  Yes

  No

  N/A

Notes/Comments:

• Overall Impression of the Site

  Developing

  Implementing

  Practicing

  Excelling

• I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible, for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

• Authorized Representative Printed Name:

• Title:

• Annual Report Certification