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 #

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

Date Signed: