j16 ADEM Form 23 BMP Inspection Report.pdf

ADEM CSW Inspection Report Form 23 11/11 1 of 2

ADEM NPDES CONSTRUCTION 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.

Item I.

Permittee Name: Facility/Site Name:

Permit Number: County:

Facility Entrance Latitude & Longitude: Phone Number:

Facility Street Address or Location Description:

Item II.

List name of current ultimate receiving water(s) (indicate if through MS4) and the number of disturbed acres which drains through each treatment system or BMP: Add additional sheet(s) if necessary.

Receiving Water Disturbed Acres Discharge Point # Representative Outfall

YES NO

YES NO

YES NO

YES NO

YES NO

Item III.

1. YES NO Did discharges of sediment or other pollutants occur from the site? If “Yes”, please list a description of the discharge(s) and their location(s):

2. YES NO Were BMPs properly implemented and maintained at the time of inspection? If “No”, please provide location(s) and descriptions of BMPs that need maintenance:

3. YES NO Are BMPs needed in addition to those already present onsite at the time of inspection? If “Yes” please provide a description and location of additional BMPs that are needed:

4. YES NO Have any BMPs failed to operate as designed? If “Yes”, please provide location(s) and description of BMP(s) that failed:

5. YES NO Were there BMPs required by the CBMPP that were not installed or installed in a manner not consistent with the CBMPP? If “Yes”, please provide a description and location where the BMPs were not installed or installed incorrectly:

Item IV.

The Permittee shall conduct turbidity monitoring in accordance with Part V of the permit:

1. YES NO Is this facility a Priority Construction Site?

2. YES NO Has the facility disturbed greater than 10 acres?

3. YES NO Was the site discharging at the time of inspection?

4. YES NO Samples collected, if “Yes”, sampling data must be attached.

ADEM CSW Inspection Report Form 23 11/11 2 of 2

Item V.

Weather Conditions:

Discharge Point # Date, Time, and Location of Samples Collected Sample Results Analytical Method(s)

“Based upon the inspection of (date & time) _______________________________ conducted by the QCP, QCI, or a qualified person (list:_______________________________________________________________) under the direct supervision of the QCP identified below. 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 the permit. 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 Permittee Responsible Official

Signature Date