APPENDIX_G_-_NYS_DEC_CORRECTIVE_ACTION_-_NON_COMPLIANCE_EVENT.pdf

Corrective Action Form/Non Compliance Event Form

Instruction for using this form:

- Complete a separate attachment for each Parameter/Pollutant of Concern exceeded and for every outfall where the exceedance occurred.

- If using this form as a Corrective Action Form, all questions (1 through 12) on each attachment must be answered

- If using this form as a Non-Compliance Event Form, questions 1, 2, 3, and 9 through 12 on each attachment must be answered

- Number each attachment (1 of XX, 2 of XX, 3 of XX, etc.)

- Initial and date each attachment

- Fill in number of attachments included in the box below

- The Owner/Operator must sign and date the certification statement below

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)

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 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 possiblity of fine and imprisonment for knowing violations.

O/O Signature First Name (please print or type) MI O/O Signature Last Name (please print or type)

Date

Signature

Contact eMail

Contact Phone

Contact Last Name

Contact First Name

Facility Name

Permit Number

Is this form being used to report a Corrective Action or a Non Compliance Event? Corrective Action Event of Non Compliance

Number of attachments included:

5748554626

1. Parameter/Pollutant of Concern Exceeded:

Exceeded:

2. Outfall No.: 3. Date of Exceedance: / /

4. Permitted Value: Units: mg/L ng/L ug/L s.u. NTUs

5. Reported Value: Units: mg/L ng/L ug/L s.u. NTUs

6. Is the Parameter/Pollutant of Concern exceeded subject to quarterly compliance monitoring for discharges to impaired waterbodies?

Yes No

If No, provide Corrective Action Sample information below. If Yes, you next quarterly sample can be used as your Corrective Action Sample.

/ /7. Corrective Action Sample Date:

Units: mg/L ng/L ug/L s.u. NTUs8. Corrective Action Sample Value:

9. Have you claimed this outfall as a Representative Outfall? Yes No

If Yes, Corrective Actions must be must be completed for all outfalls claming the Representative Outfall Waiver.

10. Describe the exceedance and its cause(s):

11. Describe the Corrective Action(s) taken to address the exceedance:

12. Describe the preventative (long term) Corrective Action(s) taken (including any SWPPP modifications) to prevent a future exceedance:

Initial:____ Date:_______Attachment of

5129554629

2. Outfall No.: 3. Date of Exceedance: / /

4. Permitted Value: Units: mg/L ng/L ug/L s.u. NTUs

5. Reported Value: Units: mg/L ng/L ug/L s.u. NTUs

6. Is the Parameter/Pollutant of Concern exceeded subject to quarterly compliance monitoring for discharges to impaired waterbodies?

Yes No

If No, provide Corrective Action Sample information below. If Yes, you next quarterly sample can be used as your Corrective Action Sample.

/ /7. Corrective Action Sample Date:

Units: mg/L ng/L ug/L s.u. NTUs8. Corrective Action Sample Value:

9. Have you claimed this outfall as a Representative Outfall? Yes No

If Yes, Corrective Actions must be must be completed for all outfalls claming the Representative Outfall Waiver.

10. Describe the exceedance and its cause(s):

11. Describe the Corrective Action(s) taken to address the exceedance:

12. Describe the preventative (long term) Corrective Action(s) taken (including any SWPPP modifications) to prevent a future exceedance:

3548554622

2. Outfall No.: 3. Date of Exceedance: / /

4. Permitted Value: Units: mg/L ng/L ug/L s.u. NTUs

5. Reported Value: Units: mg/L ng/L ug/L s.u. NTUs

6. Is the Parameter/Pollutant of Concern exceeded subject to quarterly compliance monitoring for discharges to impaired waterbodies?

Yes No

If No, provide Corrective Action Sample information below. If Yes, you next quarterly sample can be used as your Corrective Action Sample.

/ /7. Corrective Action Sample Date:

Units: mg/L ng/L ug/L s.u. NTUs8. Corrective Action Sample Value:

9. Have you claimed this outfall as a Representative Outfall? Yes No

If Yes, Corrective Actions must be must be completed for all outfalls claming the Representative Outfall Waiver.

10. Describe the exceedance and its cause(s):

11. Describe the Corrective Action(s) taken to address the exceedance:

12. Describe the preventative (long term) Corrective Action(s) taken (including any SWPPP modifications) to prevent a future exceedance:

9731554622