SWP3-ES-Jun03 2.pdf

Stormwater Pollution Prevention /Erosion & Sediment Plans For Disturbances Less Than One Acre

SWP3-ES-Jun03#2.doc

SAMPLE INSPECTION REPORT FORM (Project Name)

Erosion and Sedimentation (E&S) Control Plan Inspection and Maintenance Report Form

To be completed after every seven (7) days and within 24 hours of a rainfall event of 0.5 inches or more.

Inspector: ____________________ Date: ________________

Inspector’s Qualifications: _____________________________________________________

Days since last rainfall: _______________ Amount of last rainfall: ___________

Inspection of Disturbed Areas and Condition of Control Measures

Disturbance Location(s)

Each Area

Date of Construction Activity

Date when Construction Ceased

Are Control Practices in Place?

(Yes/No)

Condition of the Control Measures

Are Controls Working?

(Yes/No)

Is the area stabilized? (Yes/No) (Temporary/Permanent) Date of Stabilization ________

Maintenance Required:

To be performed by: _________________________ On or before: _______________

Stormwater Pollution Prevention /Erosion & Sediment Plans For Disturbances Less Than One Acre

SWP3-ES-Jun03#2.doc

SAMPLE INSPECTION FORM (Project Name) continued

Inspection of Outfalls, Drainage System, and Receiving Waters

Appearance of Receiving Water

Appearance of the Outfall Discharge to the Receiving Water

Appearance of Drainage System Outfall After Controls

Are Pollutants Entering the Drainage System? (Yes/No)

Measures taken to correct deficiencies:

Other Controls

Are Materials Stored on Site? (Yes/No)

Are Materials Kept in a Dry Covered Area?

(Yes/No)

Are Vehicles Leaking?

(Yes/No)

Is Other Equipment Leaking? (Yes/No)

Are Vehicles Inspected for Offsite Sediment Tracking? (Yes/No)

Is Soil and Mud Transported from the Site onto Roads? (Yes/No)

Measures taken to correct deficiencies:

Changes required to the E&S Plan:

“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 violation.”

Signature: ______________________________ Date: _________________