MPCA - SWPPP Inspection Form Copy

• Document No.

• Conducted on

  Date

• Prepared By:

  enter name of inspector

  Maintenance Personnel

• Name of person preparing inspection

• Business Location

  Main Facility - (add address)

  secondary location (add address)

• MPCA - SWPPP Permit No. (Add permit #)

• SIC PRIMARY CODE: 2434 (insert your specific SIC info)
  INDUSTRIAL ACTIVITY: W1 - Wood Kitchen Cabinets
  INDUSTRIAL SUBSECTOR: W - Furniture and Fixtures
  INDUSTRIAL SECTOR: Furniture and Fixtures

• MPCA - SWPPP Permit No. (Add permit number for secondary location)

• SIC PRIMARY CODE: (add your SIC info)
  INDUSTRIAL ACTIVITY: Hardwood Dimension and Flooring Mills
  INDUSTRIAL SUBSECTOR: W - Furniture and Fixtures
  INDUSTRIAL SECTOR: Timber Products

• Current Weather Information

• Atmospheric Conditions at time of Inspection

  Select Sunny Partially Cloudy Mostly Cloudy Cloudy Pre Sunrise Post Sunset Foggy Dew saturated ground

  • Sunny
  • Partially Cloudy
  • Mostly Cloudy
  • Cloudy
  • Pre Sunrise
  • Post Sunset
  • Foggy
  • Dew saturated ground

• Temperature

• Precipitation at time of inspection?

  Yes

  No

• Type of Precipitation at time of inspection

  Select Rain - Light drizzle Rain - Steady Rain - Heavy Snowfall - Light Snowfall - Heavy No

  • Rain - Light drizzle
  • Rain - Steady
  • Rain - Heavy
  • Snowfall - Light
  • Snowfall - Heavy
  • No

Areas of SWPPP Inspection and Reporting

• In accordance to the Minnesota Pollution Control's Industrial Storm Water Pollution Prevention Program Guidelines, this monthly inspection is being performed at the following facility:

  Main Facility - (add address)

  secondary location (add address)

• In accordance to the MPCA Industrial SWPPP, we are required to conduct a minimum of 1 (one) SWPPP inspection where runoff is observed during an event of precipitation.

• Was this inspection conducted during a precipitation or snowmelt event?

  Yes

  No

• Was runoff observed during this inspection?

  Yes

  No

• What type of runoff was observed?

  Rain

  Snowmelt

• What materials or concerns were noted to be seen on or in the runoff water?

  Select Oily Sheen Rusty colored appearance Milky colored appearance Muddy appearance Other

  • Oily Sheen
  • Rusty colored appearance
  • Milky colored appearance
  • Muddy appearance
  • Other

• Please describe the condition or materials noted on or in the runoff water.

Select inspection area and complete notable findings if required.

• Area of inspection:

  Select Dumpsters/recycling - lids shut Scrap metal bin Used oil tank Equipment storage area Sawdust handling equipment and loadout area Building perimeter North storage area Topcoat/Sealer filling tap area Used paint rag/filter storage area Mercury containing materials storage area Vegetated areas and drainage conveyance Other location not previously detailed

  • Dumpsters/recycling - lids shut
  • Scrap metal bin
  • Used oil tank
  • Equipment storage area
  • Sawdust handling equipment and loadout area
  • Building perimeter
  • North storage area
  • Topcoat/Sealer filling tap area
  • Used paint rag/filter storage area
  • Mercury containing materials storage area
  • Vegetated areas and drainage conveyance
  • Other location not previously detailed

• Lids are shut and no litter is noted to be outside of bins?

  Yes, No issues to report

  Concern Noted

• What is the concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Scrap metal is noted to be inside of bin?

  Yes, No issues to report

  Concern Noted

• What is the concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Residual or spilled oil present and/or exposed?

  No noted exposure or other issues to report at this time

  Yes, residual or spilled oil is present

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Any evidence of fuel or oil leaks?

  No noteable leaks recognized

  Yes, evidence of fuel or oil leaks is present

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Any accumulation of sawdust on ground?

  No, sawdust is not noted at time of inspection

  Yes, minimal amount of sawdust is present

  Yes, unacceptable amount of sawdust accumulation is present

• What area(s) is sawdust accumulation occurring?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Any exposed significant materials?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Any exposed significant materials?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Are any residual or spilled product present and exposed?

  No. Signs of residual or spilled product is not present

  Yes. Residual or spilled material is present

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Is the residual or spilled product the equivalent of 1 (one) U.S. Gallon or more?

  Yes

  No

  N/A

• Have HAZ-MAT chemical spill containment and cleanup procedures been initiated?

  Yes

  No

• Why has this process/procedure not been initiated?

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Are any materials, inside or outside of bags exposed?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Initiated liquid chemical spill containment and clean-up procedures Discussed issue with department management to discuss with delivery driver

  • Initiated liquid chemical spill containment and clean-up procedures
  • Discussed issue with department management to discuss with delivery driver

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• All materials stored properly?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Accumulation of sediment, trash or lack of vegetation present and/or sheen of oil based substance present on top of drainage water?

  Yes

  No

• Type of concern needing to be addressed and/or investigated further?

  Select Sediment accumulation Trash accumulation Lack of vegitation Sheen of oil based substance sheen present on top of water in drainage area(s)

  • Sediment accumulation
  • Trash accumulation
  • Lack of vegitation
  • Sheen of oil based substance sheen present on top of water in drainage area(s)

• Where is the area of vegetation/drainage concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No
Select inspection area and complete notable findings if required.

• Area of inspection:

  Select Dumpster/recycling Sawdust handling equipment and loadout area Building perimeter Mercury containing materials storage area Vegetated areas and drainage conveyance Other

  • Dumpster/recycling
  • Sawdust handling equipment and loadout area
  • Building perimeter
  • Mercury containing materials storage area
  • Vegetated areas and drainage conveyance
  • Other

• Lids are shut, no litter is present outside of bins?

  Yes, No issues to report

  Concern Noted

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Is accumulation of sawdust present on the ground?

  No, sawdust is not noted at time of inspection

  Yes, minimal amount of sawdust is present

  Yes, unacceptable amount of sawdust accumulation is present

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Any exposed significant materials?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• All materials stored properly?

  Yes, No issues to report

  Concern Noted

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Accumulation of sediment, trash or lack of vegetation present and/or sheen of oil based substance present on top of drainage water?

  Yes

  No

• Type of concern needing to be addressed and/or investigated further?

  Select Sediment accumulation Trash accumulation Lack of vegitation Sheen of oil based substance sheen present on top of water in drainage area(s)

  • Sediment accumulation
  • Trash accumulation
  • Lack of vegitation
  • Sheen of oil based substance sheen present on top of water in drainage area(s)

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• What is the source of concern/issue needing correction?

• Photo(s) of concern

  Media

• Corrective Action measures to be taken?

  Select Created maintenance workorder to be addressed Discussed concern/issue with EHS manager for appropriate corrective action Submitted to CCW "Refresh" group to make corrective action budget determination

  • Created maintenance workorder to be addressed
  • Discussed concern/issue with EHS manager for appropriate corrective action
  • Submitted to CCW "Refresh" group to make corrective action budget determination

• Should this concern/issue be recommended to be updated into the current SWPPP?

  Yes

  No

• Inspector Signature

  Sign