mt-r-cmr6152001_SWPPPBinder.pdf

Stormwater Pollution Prevention Plan

SWPPP

For:

Federal Highway Administration Western Federal Lands Highway Division

Tab 1

Form SWPPP Page 1 of 10

AGENCY USE ONLY

PERMIT NO.: Date Rec’d.: Amount Rec’d.: Check No.: Rec’d By:

WATER PROTECTION BUREAU

FORM

SWPPP

Storm Water Pollution Prevention Plan (SWPPP) Form Storm Water Discharge Associated With Construction Activity

MTR100000

READ THIS BEFORE COMPLETING FORM: The Form SWPPP is intended to assist operators in developing a SWPPP which complies with Part 3 of the General Permit for Storm Water Discharges Associated with Construction Activity (General Permit). It is the permittee’s responsibility to ensure all required items in the General Permit are adequately addressed and that the SWPPP is developed, implemented, and maintained.

Additional information may be needed to supplement the Form SWPPP. For additional information, please call:

(406) 444-3080 or visit: http://deq.mt.gov/wqinfo/mpdes/stormwaterconstruction.mcpx Section A - SWPPP Status: (Check one)

New No prior SWPPP submitted for this site.

Modificatio Permit Number: MTR10 __ __ __ __ (Please specify these four numbers)

Section B - Facility or Site Information:

Site Name ________________________________________________________________________________

Site Location

Nearest City or Town County Section C - Applicant (Owner/Operator) Information:

Owner or Operator Name

Mailing Address

City, State, and Zip Code

Phone Number Section D SWPPP Preparer and SWPPP Administrator SWPPP Preparer:

Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________

Form SWPPP Page 2 of 10

SWPPP Administrator: Same as above Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________

Section E – Site Description (

1. Describe the nature of the construction activity and what is being constructed.

2. Describe all support activities and associated storm water discharges dedicated to the construction activity including but not limited to: material borrow areas, material fill areas, concrete or asphalt batch plants, equipment staging areas, access roads/corridors, material storage areas, and material crushing/recycling /processing areas.

3. Provide an estimate of the total area of the site, and an estimate of the area of the site expected to undergo construction-related disturbance (including all construction-related support activities).

Total Site Area (acres): ____________ Area of Construction-Related Disturbance (acres): ____________

4. Describe the character and erodibility of soil(s) and other earth material to be disturbed at the site, including cut/fill material to be used.

SWPPP Administrator:

Name or Position Title Mailing Address City, State, and Zip Code Phone Number _____________________ Email Training Course _________________________________ Date Completed____________________________

Form SWPPP Page 3 of 10

6. For a storm water discharge associated with construction activity with construction-related disturbance of five acres or more of total land area (based on the acreage provided in item E.3 above):

a. Provide an estimate of the runoff coefficient of the site, both before and after construction, and describe what supporting information this determination is based upon:

Runoff coefficient before construction: ____________ Runoff coefficient after construction: ____________ Supporting Information Source:

b. Provide an estimate of the increase in impervious area after the construction activity is completed:

________ Percent.

Outfall Number

Receiving Surface Water Drainage Area Associated with

Type of Discharge

Latitude and Longitude of Outfall

Discharge to Municipal Storm

5. Provide a brief description of the existing vegetation at the site and an estimate of the percent density of vegetative ground cover.

Specify Percent Density of Existing Vegetation: _________________

Form SWPPP Page 4 of 10

Section – Identification and Summary of Potential Pollutant Sources (Part 3.4) Select the pollutants expected to be present on the construction project:

Additional Pollutants List any additional pollutants likely to be present at the construction project.

Non-Storm Water Discharges Select the types of allowable non-storm water discharges likely to be present at the construction project.

Type of Allowable Non-Storm Water Discharge Present at Construction Project Irrigation Drainage Landscape Watering Pavement Wash Waters Routine Building Wash Down Uncontaminated spring or ground water Water used for dust control Emergency fire-fighting activities Foundation or footing drains Incidental windblown mist from cooling towers Uncontaminated condensate from air conditioners, coolers, or other compressors Other Explain ___________________________

Soils Areas of Shallow Grade Areas of Steep Grade Slopes Ditch Stockpiles Contaminated Soils Import and Export Operations Entrance / Exit Locations Other Explain_______________________

Materials Loading and Unloading Operations Storage of building materials Storage of chemicals Portable Toilets Concrete Batch Plant Asphalt Batch Plant Worker Trash Demolition Materials / Debris Other Explain ____________________

Activities Concrete Truck Washout Masonry - Stone / Brick / Concrete Spray / Wand Applications Finish Work – Dry wall / Painting Equipment Washing Washing of Buildings Maintenance of Equipment Refueling Operations Application of herbicides, pesticides, fertilizers Application of solvents or detergents Construction Dewatering Other Explain_____________________

Form SWPPP Page 5 of 10

Section – Selection of Best Management Practices (BMPs) (Part 3.5) Select the BMPs to be used during the construction project. All selected BMPs are required to have a specification provided in the SWPPP. The specifications do not have to be submitted to DEQ. The specifications are required to be maintained by the SWPPP Administrator(s) and provided to DEQ, EPA, or other local permitting authority upon request.

Additional BMPs List any additional BMPs likely to be used at the construction project.

Erosion Control BMPs Surface Roughening Diversion Ditches Velocity Checks / Check Dams Preservation of Existing

Vegetation Minimizing Ground Disturbance Mulch – Straw / Compost Tackifiers / Soil Binders Temporary Seeding Erosion Control Blankets Rough Cut Street Controls / Water

Bars Channel Liner Stream Crossing Terracing Culvert Outfall / Outlet Protection (Rip

Rap) Other ______________________

Run On / Runoff Control BMPs Temporary Slope Drain Rock Run Down Clean Water Diversion Drainage Swales Other ______________________

Sediment Control BMPs Silt Fence Straw Wattles Rock Wattles / Rock Socks Curb Socks Straw Bales Earthen Berms Vegetative Buffers Drainage Ditch / Ditch Berm Gravel Pack Tarps, Plastic, Visqueen Compost Socks Brush Barrier Sandbag Barrier Inlet Protection Vehicle Tracking Control Pad Stabilized Vehicle Entrance Stabilized Parking Area Stabilized Construction Roadway Street Sweeping Sediment Trap Sediment Basin Other ________________________

Administrative Controls Concrete and Liquid Waste Washouts Worker Toilets Construction Fencing Dust Control Secondary Containment Dumpsters / Waste Receptacles Stabilized Staging Area Material Storage and Stockpile Area Paving and Painting Controls Saw Cutting and Grinding Controls Spill Prevention and Response

Procedures Traffic Control Back Charging / Penalties Other __________________________

Post Construction BMPs Detention Pond(s) Retention Pond(s) Drainage Swales Infiltration System(s) Dry Well(s) Other __________________________

Form SWPPP Page 6 of 10

Local Erosion and Sediment Controls Describe applicable local erosion and sediment control requirements.

Dewatering Activities (Part 3.6) Describe dewatering activities associated with the construction project. Identify the BMPs to be used to control dewatering activities and prevent discharges to state waters. If a separate authorization is obtained under the Construction Dewatering General Permit, include the dewatering plan with the SWPPP.

Se ct io n

H : M aj or

C on st ru ct io n Ac tiv ity a nd

B M

P Ph as in g (P ar t 3

.7

Id en tif y th e to ta l n um be r o f m aj or c on st ru ct io n ac tiv iti es a ss oc ia te d w ith th e pr oj ec t:

Co m pl et e th e ta bl e be lo w b y lis tin g th e m aj or c on st ru ct io n ac tiv iti es in th e to p ro w . L is t t he se le ct ed B

M Ps to b e us ed fo r t he c on st ru ct io n pr oj ec t i n th e fir st c ol um n.

S el ec t t he b ox in th e ro w a nd c ol um n th at w ill re pr es en t w he n th e

BM

P w ill b e us ed fo r e ac h m aj or c on st ru ct io n ac tiv ity

. F or a dd iti on al m aj or c on st ru ct io n ac tiv iti es a nd B

M Ps

, c om pl et e an ot he r s he et u sin g th is p ag e.

M aj or C on st ru ct io n

A ct iv it y

B M

P s

Form SWPPP Page 8 of 10

Major Construction Activity Schedule List the major construction activities identified in the table above and provide an estimated timeframe for each major construction activity. For each major construction activity, identify all construction activities that will occur during the proposed major construction activity.

Section – Final Stabilization (Part 3.8) Identify the BMPs that will be used to achieve final stabilization. Information to be included is seed mix selection and application methods, soil preparation and amendments, soil stabilization practices, and any temporary BMPs.

Section – Post-Construction Storm Water Management (Part 3.9) Identify BMPs that will be used to control storm water discharges that will occur after the major construction activities are complete. Include a description of applicable local requirements.

Form SWPPP Page 9 of 10

Section – Site Map (Part 3.10) Develop and attach the required SWPPP site maps and plans with the SWPPP. The site maps or plans must clearly indicate all the required information in Part 3. of the General Permit. This means SWPPP site maps must be of sufficient size, scale, and legibility.

Section – Inspection and BMP Maintenance Procedures (Part 3.11) Select the inspection schedule for the construction project:

Once every 7 calendar days Once every 14 calendar days, and a post-storm event inspection within 24 hours of the end of a rainfall event of 0.25 inches or greater, and/or within 24 hours of runoff from snowmelt

Describe the inspection and maintenance procedures that will be used to maintain all erosion, sediment control, and other BMPs in good and effective operating condition. Identify how changes to the SWPPP will occur per Part

3.12 of the General Permit. If post construction BMPs will be used during major construction activities, include a maintenance plan that will transition the BMP from active construction to post construction.

Section – Water Quality Controls for Discharges to Impaired Water bodies (Part )

Form SWPPP Page 10 of 10

Section O - CERTIFICATION

Permittee Information: This SWPPP must be completed, signed, and certified as follows:

For a corporation, by a principal officer of at least the level of vice president;

For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or For a municipality, state, federal, or other public facility, by either a principal executive officer or ranking elected official.

Alternatively, this SWPPP may be signed by a duly authorized representative of the person above. A person is a duly authorized representative only if:

The authorization is made in writing by a person described above;

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, position 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);

The written authorization is submitted to the department.

All Permittees Must Complete the Following Certification:

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 gather and evaluate the information submitted. Based on my inquiry of the 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. [75-5-

633, MCA]

A. Name (Type or Print)

B. Title (Type or Print) C. Phone No.

D. Signature E. Date Signed

The Department will not process this form until all of the requested information is supplied, and the appropriate fees are paid. Return this form and the applicable fee to:

Department of Environmental Quality Water Protection Bureau

PO Box 200901 Helena, MT 59620-0901

(406) 444-3080

Section – Miscellaneous Information Use this space to identify miscellaneous information that is to be included in the SWPPP.

Tab 2

Tab 3

February 10, 2022

Scott Smithline

WESTERN FEDERAL LANDS HIGHWAY DIVISION FHWA

610 E FIFTH ST

Vancouver, WA 98661

RE: Confirmation Letter, Notice of Intent (NOI) MTR109293; Charles M Russell Refuge Repairs, MT FWS CMR

61520(1)

Effective January 1, 2021 a sign or other form of notice to publicly display confirmation of coverage is required on site.

Dear Scott Smithline:

The Department of Environmental Quality (DEQ) acknowledges the receipt of your complete application package (NOI and SWPPP) to discharge under the January 01, 2018, General Permit for Storm Water Discharges Associated with Construction Activity (SWC-GP) on February 11, 2022. Your authorization number under the SWC-GP is MTR109293.

Please include this number on any correspondence with DEQ regarding this site.

This letter confirms only that a complete NOI has been received. DEQ does not assess the validity of the information you provided other than project location as it relates to sage grouse habitat. Your signature on the NOI certifies that you have read, understand, and are implementing all applicable requirements.

Specifically, the SWC-GP:

Requires implementation of a Storm Water Pollution Prevention Plan (SWPPP), Defines the inspection process, and Defines record keeping requirements (refer to Part 2.5 of the General Permit).

The SWC-GP and additional guidance materials can be viewed and downloaded from out FACTS page at http://deq.mt.gov/Public/FACTS or the MT DEQ website at http://deq.mt.gov/Water/StormWater/StormSystems.

Authorization under the SWC-GP remains in effect until you submit a complete Notice of Termination (NOT). Your signature on the NOT certifies that you have achieved final stabilization, removed your temporary Best Management Practices, and have paid all applicable fees. All effective authorizations are assessed annual fees each calendar year until a complete NOT is received.

Coverage under the SWC-GP does not waive your obligation to obtain coverage under other applicable permits. If you have questions regarding SWC-GP requirements, please contact me at (406) 444-0574 or via email catherine.culver@mt.gov.

Sincerely, Cathy Culver

FEDERAL HIGHWAY ADMINISTRATION

WESTERN FEDERAL LANDS

HIGHWAY DIVISION

DELEGATION OF AUTHORITY

I, , hereby designate the person or specifically described position below to be a duly authorized representative for the purpose of overseeing compliance with environmental requirements, including the Construction General Permit, at the construction site.

The designee is authorized to sign any reports, stormwater pollution prevention plans and all other documents required by the permit.

Name or Position:

Company:

Address:

City, State, Zip:

Phone:

Company:

Title:

Signature:

FHWA, Western Federal Lands Highway Division

610 East Fifth Street

Vancouver, WA 98661-3801

360-619-7700

By signing this authorization, I confirm that I meet the requirements to make such a designation as set forth in and that the designee above meets the definition of a �duly authorized representative� as set forth in

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.

Name:

WFLHD, Western Federal Lands Highway Division

Environmental Manager

Tab 5

Tab 7

F E

D E

R A

L H

IG

H

W A

Y A

D M

IN

IS

T R

A T

IO

N

W

S T

E R

N F

E D

E R

A L

L A

N D

S H

IG

H

W A

Y D

IV

IS

S

P P

P A

M E

N D

M E

N T

L O

G ro je ct N am e:

P ag e:

A m en d m en t N u m be r D es cr ip ti on of A m en d m en t/ B M P

Lo ca ti on of A m en d m en t/ B M P

P ag e/ Sh ee tN u m b er

D at e of

A m en d m en t A m en d m en t A p p ro ve d by

(N am e, T it le

W F

L H

D

-4

5/

Tab 9 Inspection Reports

FEDERAL HIGHWAY ADMINISTRATION

HIGHWAY DIVISION

SWPPP CONSTRUCTION SITE INSPECTION REPORT

General Information

Project Name:

Date of Inspection: Start/End Times:

Project Name:

Inspector’s Names: Inspectors Title:

Inspector’s Company:

Inspector’s Contact Information:

Inspector’s Qualifications (CESCL or other certification number): Inspector’s Qualifications expiration date:

Describe present phase of construction

Type of Inspection:

Regular Post-storm event Reduced inspection frequency period

Weather Information

Has there been a storm event since the last inspection? Yes No If yes, provide:

Estimated Storm Start Date & Time:

Estimated Storm Duration (hrs):

Approximate Amount of Precipitation (in):

Weather at time of this inspection?

Clear Cloudy Rain Sleet Fog Snowing High Winds Other:

Temperature:

WFLHD 157-2 (5/2011)

Page 2 Project Name:

Inspection Date:

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 sheets. 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?” column 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.

Delayed 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 Action 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 Installed?

BMP Action Required?

Describe BMP Action, if Needed

1 Yes No Yes No

Complete by Date:

2 Yes No Yes No

Complete by Date:

3 Yes No Yes No

Complete by Date:

4 Yes No Yes No

Complete by Date:

5 Yes No Yes No

Complete by Date:

6 Yes No Yes No

Complete by Date:

7 Yes No Yes No

Complete by Date:

8 Yes No Yes No

Complete by Date:

Page 3 Project Name:

BMP & Location BMP Installed?

BMP Action Required?

Describe BMP Action, if Needed

9 Yes No Yes No

Complete by Date:

10 Yes No Yes No

Complete by Date:

11 Yes No Yes No

Complete by Date:

12 Yes No Yes No

Complete by Date:

13 Yes No Yes No

Complete by Date:

14 Yes No Yes No

Complete by Date:

15 Yes No Yes No

Complete by Date:

16 Yes No Yes No

Complete by Date:

17 Yes No Yes No

Complete by Date:

18 Yes No Yes No

Complete by Date:

19 Yes No Yes No

Complete by Date:

20 Yes No Yes No

Complete by Date:

21 Yes No Yes No

Complete by

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

Page 4 Project Name:

Overall Site Issues BMP or Activity -- These are some general site 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, check “Yes” in this column.

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 the “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 Corrective Action Log.

BMP or Activity Implemented? Corrective Action Required?

Describe Corrective Action and Location, if Needed

1 Have stabilization measures been initiated on slopes and disturbed areas not actively being worked?

Yes No Yes No

Complete by Date:

2 Are natural resource areas (e.g., streams, wetlands, mature trees, etc.) required by the SWPPP to be delineated in the field, identified with barriers or markings?

Yes No Yes No

Complete by Date:

3 Are perimeter controls and sediment barriers adequately installed (keyed into substrate) and maintained?

Yes No Yes No

Complete by Date:

4 Are storm drain inlets properly protected?

Yes No Yes No Complete by Date:

5 Are the construction exits preventing sediment from being tracked into the street?

Yes No Yes No

Complete by Date:

6 Is trash/litter from work areas collected and placed in covered dumpsters?

Yes No Yes No

Complete by Date:

7 Are washout facilities (e.g., paint, concrete) available, clearly marked, and maintained?

Yes No Yes No

Page 5 Project Name:

BMP or Activity Implemented? Corrective Action Required?

Describe Corrective Action and Location, if Needed

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

Yes No Yes No

Complete by Date:

9 Are materials that are potential stormwater contaminants stored inside or under cover?

Yes No Yes No Complete by Date:

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

Yes No Yes No Complete by Date:

Overall Site Issue Answer to Question

Corrective Action Required?

Describe Corrective Action and Location, if Needed

1 At the time of inspection, are the discharge points and receiving waters free of pollutant discharges (sediment deposits, sediment plume or oil sheen)? (See continuation page for list of discharge points)

Yes No Yes No Complete by Date:

2 Since the last inspection, are the discharge points and receiving waters free of evidence that pollutants had left the project site (for example, sediment deposits, oily residue)? (See continuation page for list of discharge points)

Yes No Yes No Complete by Date:

3 Has Spill Response kit been used since the last inspection? If yes, has stock been maintained?

Yes No Yes No Complete by Date:

4 Are any additional BMPs needed?

Yes No Yes No Complete by

5 (Other)

Yes No Yes No

Page 6 Project Name:

Scope of Inspection

Did you inspect all areas of the project that are required to be inspected by the CGP (areas disturbed by construction activity, areas used for storage of materials that are exposed to precipitation, discharge locations and locations where vehicles enter or exit the site)?

Yes No If you did not inspect any required areas, list those locations here and explain why they weren’t inspected.

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

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 current 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 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.”

Contractor’s Duly Authorized Representative FHWA’s Duly Authorized Representative

Print name: Print Name:

Title: Superintendent Title: Project Engineer

Signature: Signature:

D E

R A

L H

IG

H

W A

Y A

D M

IN

IS

T R

A T

S T

E R

N F

E D

E R

A L

L A

N D

S H

IG

H

W A

Y D

IV

IS

C

R R

E C

T

IV

E A

C T

IO

N

L je ct N am e:

P ag e:

In sp ec ti on

D at e

In sp ec to r N am e D es cr ip ti on of B M P D ef ic ie n cy

Lo ca ti on of B M P D ef ic ie n cy

D at e Co rr ec ti ve

A ct io n T ak en

R es p on si b le P er so n

W F

L H

D

-5

5/

Tab 11

SWPPP TRAINING LOG

Sediment and Erosion Control/NPDES Training

Project Name:

Course Title:

Instructor’s Name(s)/Title(s):

Course Location:

Course Date: Course Length (hours):

Training Topics:

Erosion Control BMPs Good Housekeeping BMPs Other (Specify)

Sediment Control BMPs SWPPP Provisions

Non-Storm Water BMPs Conducting Inspections

Emergency Procedures Turbidity Monitoring

(attach additional pages as necessary)

Name of Attendee Company/Agency

WFLHD 157-3 (5/2011)

FEDERAL HIGHWAY ADMINISTRATION

HIGHWAY DIVISION

D E

R A

L H

IG

H

W A

Y A

D M

IN

IS

T R

A T

S T

E R

N F

E D

E R

A L

L A

N D

S H

IG

H

W A

Y D

IV

IS

S

P P

P G

R A

D

IN

G A

N D

S T

A B

IL

IZ

A T

IO

N

L je ct N am e:

P ag e:

D at e

G ra d in g

A ct iv it y

In it ia te d

D es cr ip ti on of G ra d in g A ct iv it y an d Lo ca ti on

D at e G ra d in g

A ct iv it y Ce as ed

(I n di ca te

T em p or ar il y or

P er m an en tl y)

D at e W h en

St ab il iz at io n

M ea su re s

In it ia te d

D es cr ip ti on of St ab il iz at io n M ea su re s

W F

L H

D

-6

5/

Quality Assurance Checklist

General Information

Project Name:

Date of Inspection:

Project Reviewed by:

Contact Information:

Describe present phase of construction:

SWPPP Information

Date of Original SWPPP:

Date of Most Recent Amendment or Modification:

Is the SWPPP signage properly and conspicuously posted? Yes No (Signage should include where the SWPPP is located, who to contact for viewing the SWPPP, and a copy of the NOI(s) if applicable)

Are the SWPPP narrative and plan sheets being updated to accurately reflect the progress of the project?

Yes No

If the answer is No to any of the above questions, the following corrective action is recommended:

Inspections (Review SWPPP documentation to assure required inspections are being performed as required)

Inspection Frequency Required by SWPPP:

At least once every 7 calendar days

At least once every 14 calendar days and within 24 hours of the end of a storm event of 0.5 inches or greater.

Are inspections being performed and documented at the above stated frequency? Yes No

Are inspection reports included in the SWPPP? Yes No Are borrow and/or waste sites dedicated to the project inspected as part of the SWPPP construction site inspection? Yes No

Are stormwater pollution controls effectively in place at borrow and/or waste sites? Yes No

Are inspections and SWPPP documentation signed by the Signatory Official? Yes No (Ensure all SWPPP documentation is signed by the Signatory Official designated in Tab 4 of the SWPPP)

Stormwater Pollution Controls

Are perimeter controls installed before any ground disturbing activities take place? Yes No

Are temporary and permanent erosion control practices properly installed and effectively maintained within the required timeframe? Yes No

Are temporary and permanent sediment control practices properly installed and effectively maintained?

Yes No

If the answer is No to any of the above questions, the following corrective action is recommended:

Are BMPs being selected, installed, implemented, and maintained as stated in the SWPPP? Yes No

Is the SWPPP being updated and revised as needed to address problems and reflect changes in the contractor’s operations? Yes No (SWPPP must be updated within 7 days of revisions, amendments, and modifications)

Are the BMPs adequate to minimize pollutants in stormwater discharge necessary to meet water quality standards as stated by the State Water Quality Certification and/or NPDES? Yes No (State Water Quality Certification found in Tab 16 of the SWPPP; NPDES permit found in Tab 2 of the SWPPP)

Tab 1

Version 2.1 August 2015 Notice of Termination Form Page 1 of 2

AGENCY USE ONLY

PERMIT NO.: Date Rec’d.: Amount Rec’d.: Check No.: Rec’d By:

FORM

NOT

Notice of Termination

Non-Storm Water General Permit Authorizations

This form is to be submitted when a discharge permit is no longer required or necessary. The Montana Department of Environmental Quality (DEQ) will notify the permittee in writing of the date termination is effective. This form may not be used to request termination of coverage under any storm water general permit. You must type or print legibly; forms that are not legible or are unsigned will be returned. Do not leave blank spaces. It is recommended that you maintain a copy of the completed form for your records.

Section A - Site Information

Permit/Authorization Number: MTG __ __ __ __ __ __

Facility or Site Name:

Facility or Site Location (physical address or Township/Range/Section):

Facility or Site Mailing Address (if available)_____________________________________________________

Nearest City or Town ___________________ State________ Zip Code___________ County_______________

Latitude: _____________________ Longitude:

Section B - Owner/Operator (Regulated Entity) Information

Owner/Operator Name:

Signatory Name and Position Title:

Mailing Address:

City: State: Zip Code:

Phone: Email:

Section C - Annual Fees

There are no fees associated with terminating permit coverage. However, the permittee is responsible for payment of annual fees for each calendar year in which the discharge is authorized, and annual fees are billed in arrears. You may contact DEQ at (406) 444-3080 to receive an invoice for the outstanding annual fees associated with your effective permit coverage, or one will be mailed to you.

Section D – Required Reports

You are required to comply with all conditions and reporting requirements until notified by DEQ that your general permit authorization is terminated, including submission of Discharge Monitoring Reports.

WATER

PROTECTION

BUREAU

Version 2.1 August 2015 Notice of Termination Form Page 2 of 2

Section E - Explanation

Indicate the reason for the termination of above referenced permit by checking the most appropriate box, and provide a detailed description in the space provided below:

Discharge terminated or will be terminated by DATE ____________________;

Discharge permanently terminated by connection to a wastewater treatment plant (WWTP);

Date discharge connected or will connect to WWTP: _______________________________

Provide name and MPDES permit number of WWTP:__________________________

Other________________________________________________________

Please provide a detailed explanation in the space below (attach additional pages if needed) of why the permit/authorization is no longer needed. Please refer to the Standard Conditions section of your permit and include any information specified in your permit required for permit termination.

Section F - CERTIFICATION

Permittee Information: This form must be completed, signed, and certified as follows:

For a corporation, by a principal officer of at least the level of vice president;

For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or For a municipality, state, federal, or other public facility, by either a principal executive officer or ranking elected official.

All Applicants Must Complete the Following Certification 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 gather and evaluate the information submitted. Based on my inquiry of the 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. [75-5-633, MCA] A. Name (Type or Print)

B. Title (Type or Print) C. Phone No.

D. Signature E. Date Signed

Return this form (NOT) to:

Department of Environmental Quality Water Protection Bureau

P.O. Box 200901 Helena, MT 59620-0901

(406) 444-3080