j16bmpinspect500.xls

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&CATTACHMENT J16

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MBD0122F98F.pdf

ADEM Form 500 1-03 FOD Stormwater Registration Inspection Report.doc Page 1 of 1

ADEM FIELD OPERATIONS DIVISION – NPDES CONSTRUCTION, AND NONCOAL MINING LESS THAN

5 ACRES STORMWATER INSPECTION REPORT AND BMP CERTIFICATION

RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES WILL BE RETURNED AND MAY RESULT IN APPROPRIATE COMPLIANCE ACTION BY THE DEPARTMENT. IF SPACE IS

INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. PLEASE TYPE OR PRINT IN INK.

Complete this form, attach additional information as necessary, and send report to the nearest ADEM office.

Item I.

Registrant Name Facility/Site Name

NPDES

AL

County Facility Contact and Title

Facility Latitude & Longitude (decimal or deg,min,sec) Facility Street Address or Location Description

Township(s), Range(s), Section(s) City State Zip

Phone Number Fax Number E-Mail Address

Item II.

List name of current ultimate receiving water(s) (indicate if through MS4) and the number of disturbed acres which drain through each treatment system or BMP:

Receiving Water Disturbed Acres Receiving Water Disturbed Acres

Item III.

Any Discharge Sampling Data Attached. Any Instream Sampling Data Attached. Any Photographs attached.

Based on this site evaluation which a QCI, QCP, or a qualified person under the direct supervision of a QCP conducted, discharge and/or instream sampling is not necessary to properly evaluate the effectiveness of BMP implementation to ensure compliance with this registration. I understand that it is the responsibility of the registrant to know and effectively evaluate the quality of the stormwater being discharged. Lack of knowledge regarding the requirements of ADEM Administrative Code Chapter 335-6-12, stormwater discharge or instream water quality, shall not constitute a valid defense with regard to deficiencies in BMP implementation and maintenance, or negative impacts to water quality.

Item IV.

INSPECTION RESULTS: (Describe current activities, deficiencies, proposed corrective action(s) and compliance schedule, etc.)

“Based upon the inspection of (date & time) _______________________________ by the QCP, QCI, or a qualified person

(list:_______________________________________________________________) under the direct supervision of the QCP identified below conducted, the QCI or QCP identified below certifies that effective structural and non-structural BMPs have been fully implemented and regularly maintained to the maximum extent practicable for the prevention and minimization of all sources of pollution in stormwater and authorized related process wastewater runoff, except for those deficiencies noted above, in accordance with the facility’s CBMPP, good sediment, erosion, and other pollution control practices, and the requirements of ADEM Administrative Code Chapter 335-6-12. I certify that discharges have been tested or evaluated for the presence of non-stormwater and non-authorized process wastewaters. 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 certify that this form has not been altered, and if copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”

Name & Designation of QCI or QCP Signature Date

Name & Title of Registrant Responsible Official Signature Date