APPENDIX_I_-_NYS_DEC_STORM_EVENT_DATA_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)

Storm Event Data Form

Contact eMail

Contact Phone

Contact Last Name

Contact First Name

Facility Name

Permit Number

/ /Storm Event Date:

(in hours).Storm Duration:

Rainfall measurment from Storm Event: . (in inches)

Date of last measurable Storm Event: / /

Duration between Storm Event sampled and end of previous measurable Storm Event: . (in hours)

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

6726335350