Fillable Printable Annual Reporting Form - Environmental Protection Agency
Fillable Printable Annual Reporting Form - Environmental Protection Agency
Annual Reporting Form - Environmental Protection Agency
NPDES Permit Tracking No.:
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
Annual Reporting Form
A. GENERAL INFORMATION
1. Facility Name:
2. NPDES Permit Tracking No.:
3. Facility Physical Address:
a. Street:
b. City:
c. State:
d. Zip Code:
-
4. Lead Inspectors Name:
Title:
Additional Inspectors Name(s):
5. Contact Person:
Title:
Phone:
- -
Ext.
E-mail:
6. Inspection Date:
/ /
B. GENERAL INSPECTION FINDINGS
1. As part of this comprehensive site inspection, did you inspect all potential pollutant sources, including areas where industrial activity may be exposed to stormwater?
YES NO
If NO, describe why not:
NOTE: Complete Section C of this form for each industrial activity area inspected and included in your SWPPP or as newly identified in B.2 or B.3 below where pollutants
may be exposed to stormwater.
2. Did this inspection identify any stormwater or non-stormwater outfalls not previously identified in your SWPPP? YES NO
If YES, for each location, describe the sources of those stormwater and non-stormwater discharges and any associated control measures in place:
NPDES Permit Tracking No.:
3. Did this inspection identify any sources of stormwater or non-stormwater discharges not previously identified in your SWPPP?
YES NO
If YES, describe these sources of stormwater or non-stormwater pollutants expected to be present in these discharges, and any control measures in place:
4. Did you review stormwater monitoring data as part of this inspection to identify potential pollutant hot spots? YES NO NA, no monitoring performed
If YES, summarize the findings of that review and describe any additional inspection activities resulting from this review:
5. Describe any evidence of pollutants entering the drainage system or discharging to surface waters, and the condition of and around outfalls, including flow
dissipation measures to prevent scouring:
6. Have you taken or do you plan to take any corrective actions, as specified in Part 3 of the permit, since your last annual report submission (or since you received
authorization to discharge under this permit if this is your first annual report), including any corrective actions identified as a result of this annual comprehensive site
inspection?
YES NO
If YES, how many conditions requiring review for correction action as
specified in Parts 3.1 and 3.2 were addressed by these corrective actions?
NOTE: Complete the attached Corrective Action Form (Section D) for each condition identified, including any conditions identified as a result of this comprehensive
stormwater inspection.
NPDES Permit Tracking No.:
C. INDUSTRIAL ACTIVITY AREA SPECIFIC FINDINGS
Complete one block for each industrial activity area where pollutants may be exposed to stormwater. Copy this page for additional industrial activity areas.
In reviewing each area, you should consider:
• Industrial materials, residue, or trash that may have or could come into contact with stormwater;
• Leaks or spills from industrial equipment, drums, tanks, and other containers;
• Offsite tracking of industrial or waste materials from areas of no exposure to exposed areas; and
• Tracking or blowing of raw, final, or waste materials from areas of no exposure to exposed areas.
INDUSTRIAL ACTIVITY AREA ______:
1. Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised control measures necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
INDUSTRIAL ACTIVITY AREA ______:
1. Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised c necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
INDUSTRIAL ACTIVITY AREA ______:
Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised BMPs necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
NPDES Permit Tracking No.:
NOTE: Copy this page and attach additional pages as necessary
INDUSTRIAL ACTIVITY AREA ______:
1. Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised BMPs necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
INDUSTRIAL ACTIVITY AREA ______:
1. Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised BMPs necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
INDUSTRIAL ACTIVITY AREA ______:
1. Brief Description:
2. Are any control measures in need of maintenance or repair? YES NO
3. Have any control measures failed and require replacement? YES NO
4. Are any additional/revised BMPs necessary in this area? YES NO
If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached
Corrective Action Form)
NPDES Permit Tracking No.:
D. CORRECTIVE ACTIONS
Complete this page for each specific condition requiring a corrective action or a review determining that no corrective action is needed. Copy this
page for additional corrective actions or reviews.
Include both corrective actions that have been initiated or completed since the last annual report, and future corrective actions needed to address problems
identified in this comprehensive stormwater inspection. Include an update on any outstanding corrective actions that had not been completed at the time of your
previous annual report.
1. Corrective Action #
of
for this reporting period.
2. Is this corrective action:
An update on a corrective action from a previous annual report; or
A new corrective action?
3. Identify the condition(s) triggering the need for this review:
Unauthorized release or discharge
Numeric effluent limitation exceedance
Control measures inadequate to meet applicable water quality standards
Control measures inadequate to meet non-numeric effluent limitations
Control measures not properly operated or maintained
Change in facility operations necessitated change in control measures
Average benchmark value exceedance
Other (describe): ________________________________
4. Briefly describe the nature of the problem identified:
5. Date problem identified:
/ /
6. How problem was identified:
Comprehensive site inspection
Quarterly visual assessment
Routine facility inspection
Benchmark monitoring
Notification by EPA or State or local authorities
Other (describe): ________________________________
7. Description of corrective action(s) taken or to be taken to eliminate or further investigate the problem (e.g., describe modifications or repairs to control
measures, analyses to be conducted, etc.) or if no modifications are needed, basis for that determination:
8. Did/will this corrective action require modification of your SWPPP? YES NO
9. Date corrective action initiated:
/ /
10. Date correction action completed:
/ /
or expected to be
completed:
/ /
11. If corrective action not yet completed, provide the status of corrective action at the time of the comprehensive site inspection and describe any remaining steps
(including timeframes associated with each step) necessary to complete corrective action:
NPDES Permit Tracking No.:
E. ANNUAL REPORT CERTIFICATION
1. Compliance Certification
Do you certify that your annual inspection has met the requirements of Part 4.2 of the permit, and that, based upon the results of this inspection, to the best of
your knowledge, you are in compliance with the permit?
YES NO
If NO, summarize why you are not in compliance with the permit:
2. Annual Report 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 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.
Authorized Representative
Printed Name:
Title:
Signatur
e:
Date Signed:
