ESCP OR FS ERFO 2016(1)-15(3).pdf

The authorization, is made in writing by a-person described in Appendix G, Subsection I I .A;

The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, positfon of equivalent responsibility, or an individual or position having overall responsibility for environmental matters for the company. (A duly authorized representative may thus be either a named individual or any individual occupying a named position); and ·

The signed and dated written authorization is included in the SWPPP. A copy must be submitted to EPA, if requested. ·

FEDERAL mGHWAY ADMINISTRATION WESTatN FEDERAL L.A?IDS

BIGllWAYDMSION

SWP:('P CONS'l'RUCTION SITE INSPECT.ION REPORT

Project :Name:

Date of Inspectio~: Start/End Times:

Project :Name:

Inspector's Names:

lnspector's Comvany:

Inspector's Contact Information:

Inspector's Qualifications (CES.CL or other certification ~number): Inspector's Qualifications expiration date:

Descdbe present phase of construction

Type of Inspection:

0Regular D Post-storm.event D Reduced inspection frequency period

Has there been a stor~ event since tbelasfinspection? D Yes No If yes, provide:

Estimated Storm Start Date & Time:._. ------ Estimated Sto~ Duratioµ (hrs):

Approximate Amount of Precipitation (in):------

Weather at time oftbis inspection?

D Clear 0Cloudy D Rain D Sleet 0Fog D Snowing D High Win.ds D Other:

Tempetature: ______ _

WFLHD 157-2 (5/201l)

5.

Site-specific BMPs

• BMP - Describe and give the location of the structural and non-structural BMPs identified in your SWPPP in the BMP column below (add as many BMPs as necessary on the continuation $heets. Include areas that are required to be inspected by the CGP, such as material storage areas that are exposed to precipitation.

• BMP Installed:... If a BMP should be installed at the current phase of the project and you marked "No " in the "BMP Installed" column, then you must check "Yes" in the "BMP Action Required?" colu_mn

• BMP.Action Required? - .If a BMP needs repair, modification, replacement, maintenance or a new BMP is needed or a SWPPP amendment is needed, then a BMP Action is required.

• BMP Action Required, Complete by Date - Before certifying the report, fill in the date when the BMP Action can reasonably be expected to be completed. When a BMP Action is NOT required, leave the "Complete by Date" blank. ·

• Describe BMP Action, if Needed -Anytime you check "Yes" for "BMP Action Required", then you must also fill in the "Describe BMP Action" column.

• Delay¢ Action Item Report - When a BMP Action is required and the Complete by Date is not met, you must then fill out the Delayed Action Item Report to explain why the date was not met. Keep the Delayed A9tion Item Report in the SWPPP. · ·

• Corrective Action Log - When a BMP Action is required as noted in this report, you must also enter all the

· information for this action in the Corrective Action Log.

BMP & Location BMP BMPAction Describe BMP Action, if Needed Installed? Reauired?

UYes LJNo LJYes 0No

Complete by Date:

0Yes LJNo LJYes 0No

Complete by Date:

0Yes 0No UYes 0No

Complete by Date:

0Yes 0No 0Yes UNo

Complete by Date:

UYes 0No UYes 0No

Complete by Date:

0Yes 0No LJYes 0No

Complete by Date:

LJYes 0No UYes 0No

Complete by Date:

UYes 0No LJYes 0No

Complete by Date:

Page2 Project Name:

Inspection Date:

BMP & Location BMP BMPActj.on Describe BMP Action, if Needed Installed? Required?

9 0Yes LJNo LJYes 0No

Complete by Date:

·10 LJ Yes .L)No LJYes LJNo

Complete by Date:

11 LJYes 0No LJYes LJNo

Complete by Date.:

12 LJYes LJNo LJYes· LJNo

Complete by "

Date:

13 0Yes LJNo LJYe5 LJNo

Complete by Date:

14 0Yes 0No LJYes LJNo

Complete by· Date:

15 0Yes 0No LJYes LJNo

Complete by Date:

16 0Yes 0No 0Yes LJNo

Complete by Date:

17 0Yes LJNo LJYes LJNo

~mpleteby

Date:

18 0Yes 0No 0Yes LJNo

Complete by Date:

19 0Yes lJNo 0Yes UNo

Complete by Date:

20 LJYes 0No 0Yes LJNo

Complete by Date:

21 LJYes 0No OYes.LJNo

Complete by Date:

• Please use continuation sheets if there are additional BMPs to list.

Page 3 Project Name:

Overall Site Issues

• BMP or Activity · -- These are some general §ite issues that must be assessed during inspections.

• Implemented? - If a BMP or activity should be implemented at the current phase· of the project and you check "No", then you must mark "Yes" in the "Corrective Action Required?" column.

• . Corrective Action Required? - When maintenance or some other corrective action is required, ~heck

"Yes " in this co.lumn.

• Corrective Action Required, Complete by Date - When a corrective action is required, before certifying the report, fill in the date when the corrective action can reasonably be expected to be completed. When a corrective action is NOT required, leave th~ "Complete by Date" blank. .

• Describe Corrective Action, if Needed -Anytime you check "Yes" in the "Corrective Action Required?"

column, you must fill in the "Describe Corrective Action " column as well.

• Delayed Action Item Report - When a Corrective Action is required and the Complete by Date is not met, you must then fill out the Delayed Action Item Report to explain why the date was not met. Keep the Delayed.Action Item Report in the SWPPP.

• Corrective Action Log - When a Corrective Action is required as noted in this report, you must also enter all the information for this action in the Co~rective Action Log.

BMP or Activity Implemented? Corrective Describe Corrective Action and Location, if Needed Action Required?

Have stabilization LJYes LJNo LJYes UNo measures been initiated on slopes and disturbed Complete ·by areas not actively being Date:

worked?

Are natural resource 0Yes 0No 0Yes 0No areas (e.g., streams, wetlands, mature trees, Complete by etc.) required by the Date:

SWPPP to be delineated ..

in the field, identified with barriers or markings?

Are perimeter controls LJYes 0No UYes UNo and sediment barriers . adequately installed Complete by (keyed into substrate) .Date:

and maintained?

Are !ltO!Jll drain inlets 0Yes 0No 0Yes UNo prpperly protected? Complete by

Date:

Are the construction UYes UNo UY~ LJNo exits preventing sediment from being Complete by tracked· into the street? Date:

Is trash/litter from work LJYes LJNo LJYes LJNo areas collected and placed in covered Complete by dumpsters? Date:

Are washo~t faciliti~ LJYes LJNo LJYes UNo (e.g., paint, concrete) available, clearly Complete by marked, and maintained? Date:

Page4 Project Name:

Bl\'.IP or Activity Implemented? Corrective Describe Corrective Action and Location, if Needed '

Action Required?

8 Are vehicle and 0Yes 0No 0Yes 0No equipment fueling, cleaning, and Complete by maintenance areas free Date:

of spills, leaks, or any other deleterious material?

9 Are materials that are 0Yes 0No 0Yes 0No potential stormwater Complete by contaminants stored Date:

inside or under cover?

IO Are non-stormwater 0Yes 0No 0Yes 0No discharges (e.g., wash Complete by water, dewatering) Date:

properly controlled?

Overall Site Issue Answer to Corrective Question Action Describe Corrective Action and Location, if Needed

Reouiroo?

I· At the time of 0Yes LJNo 0Yes UNo inspection, are the Complete by discharge points and Date:

receiving waters free of pollutant discharges (sediment deposits, sediment plume or oil

(; sheen)? (See continuation page for list of discharge points)

2 Since the last inspection; UYes UNo LJYes UNo are the discharge points Complete by and receiving waters free Date:

of evidence that pollutants had left the project site (for example, sediment deposits, oily residue)?. (See continuation page for list . of discharge points)

3 Has Spill Response kit 0Yes 0No LJYes 0No been used since the last Complete by inspection? If yes, has Date:

stock been maintained?

4 . Aie any additional 0Yes 0No OYes 0No BMPs needed? Complete by

Date:

5 (Other) LJYes LJNo LlYes LJNo

0 Complete by Date:

Page5 Project Name:

Scope oflnspection

Did you inspect all areas of the project that are UYes UNo If you did not inspect any required.areas, list those required to be inspected by th~ CGP (areas locations here and explain why they weren't inspected.

disturbed by construction activity, areas used for storage of materials that are exposed to precipitation, discharge locations and locations .where vehides enter or ex.it the site)?

• Check the box below if the project is in compliance with the CGP and the SWPPP:

D I certify that on the date of this inspection, this project was found to be in compliance with the terms of its Storm Water·Pollution Prevention Plan and the curr~nt Construction General Permit.

• If there are incidences of non-compliance, then do not check the box above. .

• When you don't check the box above, then you must describe each incident of non-compliance and the· actions that are·needed to bring the project into compliance.

• If there is an Action Item described in the non-compliance box· that does not already have a "Complete by

Date" assigned elsewhere in this report, then add a completion date within the box.

Non-Compliance

Incidence of Non-compliance:

Action Item and Complete by Date:

CERTIFICATION STATEMENT

"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system desigried 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 infonnation, the infonnation submitted is,· to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are signifieant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."

Contractor's Duly Authorized Representative FHW A's Duly Authoriied Representative

Print name: Print Name:·

Title: Superintendent Title: Proj~t Engineer Signature: Signature:

Page6 Project Name: