Annual Industrial Stormwater Site Inspection Report

• Conducted on

  Date

• Prepared by

• Inspector Contact Information

• Location
  Address

• Permit No. G-MC11-0003

Weather Information

• Weather at time of this inspection?

  Select Clear Cloudy Rain Sleet Fog Snowing High Winds

  • Clear
  • Cloudy
  • Rain
  • Sleet
  • Fog
  • Snowing
  • High Winds

• Temperature

Discharge / Spill Information

• Have any discharges or spills occurred since the last inspection?

  Yes

  No

  N/A

• Describe last discharge / spill:

• Are there any discharges / spills at the time of inspection?

  Yes

  No

  N/A

• Describe current discharge / spill:

BMP / Activity

• 1 - Is hazardous waste storage room free from spills?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order

• Add media

  Media

• 2 - Are unloading and loading areas covered to prevent materials from being exposed to rain water?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order

• Add media

  Media

• 3 - Are security doors to hazardous waste and propane storage areas adequately maintained?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order

• Add media

  Media

• 4 - Are run off channels and receiving waters free of any sediment deposits?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order Number

• Add media

  Media

• 5 - Is trash/litter from work areas collected and placed in covered dumpsters?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order Number

• Add media

  Media

• 6 - Are vehicle and equipment fueling, cleaning, and maintenance areas free of spills, leaks, or any other deleterious material?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Add media

  Media

• 7 - Are materials that are potential stormwater contaminants stored inside or under cover?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order Number

• Add media

  Media

• 8 - Are non-stormwater discharges (e.g., wash water, dewatering) properly controlled?

• Implemented

  Off

  On

• Corrective Action Needed and Notes

• Maintenance Required

  Off

  On

• Enter Work Order

• Add media

  Media

Compliance / Non-Compliance

• Was the facility in compliance with the SWPP and conditions of the permit?

  Yes

  No

  N/A

• Describe any incidents of non-compliance not described above:

Certification Satement

• “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.”

• Type name and title:

• Signature:

  Sign

• Select date

  Date