APPENDIX_H_-_NYS_DEC_ANNUAL_CERTIFICATION_REPORT.PDF

Annual Certification Report SPDES Multi-Sector General Permit for Stormwater

Discharges Associated with Industrial Activity (GP-12-01-001)

The owner/operator shall complete this Annual Certification Report form by answering the following questions, describing improvements to the facility's Stormwater Pollution Prevention Plan (SWPPP), providing copies of monitoring results on appropriate Discharge Monitoring Reports forms and signing the certification at the end of this form. This completed report is to be submitted each calendar year by February 28th of the following year to:

MSGP Permit Coordinator NYSDEC, Bureau of Water Compliance 625 Broadway, Albany, NY, 12233-3506

SECTION I: FACILITY INFORMATION:

SECTION II: GENERAL INFORMATION:

SECTION III: QUARTERLY VISUAL MONITORING:

B. Has the facility's SWPPP been updated to include modification to existing BMPs or installation of new BMPs to prevent stormwater pollution and contamination from reoccurring (See Part IV.B.1.a.(5)(c) of the MSGP)?

Yes No

3. Is the information provided in your original Notice of Intent (NOI) submission still accurate and up to date? If not, please submit a Notice of Modification (NOM) to update the facility information

A. Were corrective and follow up actions taken (See Part IV.B.1.a.(5) of the MSGP)?

2. Is the facility claiming any monitoring waiver(s)? ...................................................................................................... Yes No

* If you are claiming a monitoring waiver the appropriate monitoring waiver form must be included with your Discharge Monitoring Report form.

Adverse Climatic Conditions*

Alternate Certification of "Not Present" or "No Exposure"

Inactive or Unstaffed Site*

Representative Outfall*

Yes No4. Has a comprehensive Site Compliance Inspection and Evaluation been conducted at the facility in the past year? ...

5. Is the facility's Stormwater Pollution Prevention Plan (SWPPP) kept up to date and modified when necessary? ...... Yes No

Yes No

1. Have the required quarterly visual examinations of stormwater at the facility been performed during this reporting period (See Part.IV.1.a of the MSGP)?

2. Did any of the quarterly visual examinations result in observations of color, odor, clarity, floating solids, settled solids, suspended solids, foam, oil sheen, or other indicators of stormwater pollution and contamination? (If yes, question 2.A, 2.B, and 2.C below must be answered) ................................................................................................... Yes No

C. Was a follow up visual inspection conducted to ensure corrective and follow up actions were successful (See Part IV.B.1.a.(5)(d) of the MSGP)?

1. List the number of stormwater outfalls at the facility that are from areas of industrial activity

If yes, which waiver(s) are you claiming?

Yes No

Yes No

Yes No

Report for Calendar Year:Permit I.D. No.: NYR00

Owner Name

Facility Name

8812243503

SECTION IV: STORMWATER MONITORING - BENCHMARK PARAMETERS:

1. Is the owner/operator required to monitor stormwater at the facility for benchmark parameters (See Part IV.B.1.c)?

(If no, proceed to Section V)

3. Were any of the sampling results from this year higher than the benchmark cut-off concentrations listed in the permit? (If yes, questions 3.A and 3.B below must be answered)

2. Were there any monitoring problems? (Answer "Yes" if storm event criteria was not met or if the laboratory indicated quality assurance/quality control problems)

1. Is the owner/operator required to conduct compliance monitoring for storm water discharges from coal piles (See Part IV.B.1.d of the MSGP? (If no, proceed to Section VI)

2. Were any non-stormwater dischargers or indicators of non-stormwater discharges identified? (If no, proceed to Section IV)

1. Was the annual dry weather flow inspection performed during this reporting period (See Part IV.B.1.b of the

MSGP)?

SECTION III: ANNUAL DRY WEATHER FLOW MONITORING:

4. Is the source an allowable non-stormwater discharge (i.e., discharge covered by another SPDES permit or an allowable non-stormwater discharge covered in Part I.C.3 of the MSGP)? (If yes, question 4.A. below must be answered; if no, proceed to question 5)

3. Was the source of the non-stormwater discharge identified? (If no, proceed to question 5)

Yes No

Yes No

5. Were corrective and follow up actions taken to eliminate the unauthorized non-stormwater discharge (See Part IV.B.1.b.(3) of the MSGP)?

A. Were corrective and follow up actions taken (See Part IV.B.1.c.(6) of the MSGP)?

B. Has the facility's SWPPP been updated to include modification to existing BMPs or installation of new BMPs to prevent the benchmark exceedance from reoccurring (See Part IV.B.1.c.(6)(c) of the MSGP) ?

Note: If you had a benchmark exceedance your Corrective Action Form with follow up sample results are due by June 30 (See Part IV.B.1.c.(6)(d)(iii) of the MSGP).

3. Were any of the sampling results from this year higher than the effluent limitations listed in Table IV-1 of the MSGP? (If yes, questions 3.A and 3.B. below must be answered)

Yes No

Yes No

Yes No

2. Were there any monitoring problems? (Answer "Yes" if storm event criteria was not meet or if the laboratory indicated quality insurance assurance/quality control problems)

A. Were corrective and follow up actions taken (See Part IV.B.1.d.(6) of the MSGP)?

B. Has the facility's SWPPP been updated to include modification to existing BMPs or installation of new BMPs to prevent the effluent limitation exceedance from reoccurring (See Part IV.B.1.d.(6) of the MSGP)?

Note: If you had a effluent limitation exceedance your Corrective Action Form with follow up sample results are due by June 30 (See Part IV.B.1.e.(5)(e)(ii) of the MSGP).

SECTION V: STORMWATER MONITORING - COAL PILE RUNOFF:

Yes No

Yes No

Yes No

A. Has the facility's SWPPP been updated to address the newly identified allowable non-stormwater discharge(s) (See Part IV.B.1.b.(3)(d) of the MSGP)?

Note: If it is not possible to eliminate the non-authorized stormwater discharge the owner/operator must notify the Department with 14 days.

6. Were corrective and follow up actions successful in eliminating the unauthorized non-stormwater discharge?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

1844243501

B. Has the facility's SWPPP been updated to include modification to existing BMPs or installation of new BMPs to prevent the benchmark cutoff concentrations or effluent limitations exceedance from reoccurring (See Part IV.B.1.g.(6)(c) of the MSGP)?

A. Were corrective and follow up actions taken (See Part IV.B.1.g.(6) of the MSGP)?

3. Were any of the sampling results from this year higher than the benchmark cut-off concentrations or effluent limitations listed in the permit? (If yes, questions 3.A and 3.B below must be answered)

2. Were there any monitoring problems? (Answer "Yes" if storm event criteria was not meet of if the laboratory indicated quality insurance assurance/quality control problems)

1. Is the owner/operator required to conduct compliance monitoring for discharges to impaired waterbodies (See Part IV.B.1.g of the MSGP)? (If no, proceed to Section VIII)

SECTION VII: STORMWATER MONITORING - DISCHARGES TO IMPAIRED WATERBODIES:

SECTION VIII: SUMMARY:

Provide a brief description of any facility changes; problems identified during comprehensive compliance evaluations, quarterly visual observations or monitoring results; and actions taken to improve the quality of the stormwater discharge.

Note: If you had an effluent limitation exceedance your Corrective Action Form with follow up sample results are due by June 30 (See Part IV.B.1.e.(5)(e)(ii) of the MSGP).

B. Has the facility's SWPPP been updated to include modification to existing BMPs or installation of new BMPs to prevent the effluent limitation exceeding from reoccurring (See Part IV.B.1.e.(5)(c) of the MSGP?

A. Were corrective and follow up actions taken (See Part IV.B.1.e.(5) of the MSGP)?

3. Were any of the sampling results from this year higher than the effluent limitations listed in the permit? (If yes, questions 3.A and 3.B. below must be answered)

2. Were there any monitoring problems? (Answer "Yes" if storm event criteria was not meet of if the laboratory indicated quality insurance assurance/quality control problems)

1. Is the owner/operator required to conduct compliance monitoring for storm water discharges subject to Point Source Category Effluent Limitations (See Part IV.B.1.e of the MSGP)? (If no, proceed to Section VII)

SECTION VI: STORMWATER MONITORING - COMPLIANCE MONITORING

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

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.

Owner/Operator First Name (please print or type) MI

Owner/Operator Last Name (please print or type)

Date

CERTIFICATION

Owner/Operator Signature

C. Did the follow-up quarterly sample show the corrective and follow up actions to be successful? ...................... Yes No

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