APPENDIX_D_-_NYS_DEC_QUARTERLY_VISUAL_INSPECTION_FORM.PDF

New York State Department of Environmental Conservation Division of Water

Bureau of Water Permits 625 Broadway, Albany, New York 12233-3505

Phone: (518) 402-8111 Fax:(518) 402-9029 Website: http://www.dec.ny.gov/

Multi-Sector General Permit for Stormwater Discharges Associated with Industrial Activities

(GP-0-12-001)

Quarterly Visual Monitoring Form

2. Is the stormwater clear or transparent? ...................................................................................................................... Yes No

Clear Milky OpaqueIf yes, which of the following best describes the clarity of the stormwater:

Rainbow Sheen Floating Oil GlobulesIf yes, which best describes the sheen?

3. Can you see a rainbow sheen effect on the water surface?......................................................................................... Yes No

Yes No

If yes, describe

1. Does the stormwater appear to be colored?

If yes, describe

Yes No4. Does the sample have an odor?

Date/TimeExamined

Date/Time Collected

Quarter/Year

RainfallAmount Qualifying Storm?

Yes No

Runoff Source?

Rainfall Snowmelt

Outfall Number Examiner'sName Examiner'sTitle

Permit Number Facility Name

/AM PM /AM PM

5595231651

StormwaterExaminer'sSignature

Detail any concerns, corrective actions taken and any other indicators of pollution present in the sample:

5. Is there something floating on the surface of the sample? ......................................................................................... Yes No

If yes, describe

Yes No6. Is there something suspended in the water column of the sample?

If yes, describe

Yes No7. Is there something settled on the bottom of the sample?

If yes, describe

If yes, describe

Yes No8. Is there foam or material forming on the top of the sample surface?

9138231658