Fillable Printable Form 53590
Fillable Printable Form 53590
Form 53590
RULE 6 INDUSTRIAL STORM WATER
GENERAL PERMIT – ST ORM WATER
DISCHARGE MONITORING REP ORT
State Form 53590 (R /12-09)
INDIANA DEPARTMENT OF
ENVIRONMENTAL MANAGEMENT
Rule 6 Coordinator
100 North Senate Avenue,
Mail Code 65-42, Room 1255
Indianapolis, IN 46204-2251
Telephone (317) 233-0202
Toll free (800) 451-6027(within Indiana), ext. 30202
www.idem.IN.gov
W
eb Access: www.IN.gov/idem/4901.htm
MONITORING REQUIREMENTS
• YEAR ONE (1) - 327 IAC 15-6-7.3 This form must be submitted within one (1) year of the original or renewal NOI letter submittal and prior
to implementation of the “Storm Water Pollution Prevention Plan.” A permitted facility shall sample and analyze the discharge from the
outfall(s) identified in the approved NOI letter.
• YEARS TWO (2) through Five (5) - Subsequent annual sampling data shall be provided no later than three hundred sixty-five (365) days
from submittal of the previous report in years Two (2) through Five (5).
• There should be a minimum of at least three (3) months between reported sampling events.
• Samples shall be taken from a storm event. Run-off resulting from snow or ice melt should not be used to meet the annual monitoring
requirements.
• Attachments − Submit a complete copy of the laboratory report, including chain-of-custody.
• Please submit this form and attachments to IDEM at the address in the box in the upper right hand corner of this form within thirty (30)
days after laboratory analyses have been completed.
PART A: PERMIT INFORMAION
1. Facility permit number
2. Facility name
3. Facility address (number and street)
4. City 5. ZIP code 6. County
7. Contact Person
8. Contact telephone number
() -
9. E-mail address
10. Sample Year (permit year) Year 1 Year 2 Year 3 Year 4 Year 5
11. Laboratory completing the analysis
12. Date laboratory analysis was completed
(month, day, year)
/ /
13. The laboratory report, including the Chain-of Custody has been attached to this submittal Yes No
PART C: FIELD SAMPLING DATA
Insert Field Data Sheet Information
14. Person collecting sample
15. Outfall(s) sampled
16. Description of outfall
17. Date of sample collection
(month, day, year)
/ /
18. Start of discharge (date and time) / / :
19. Duration of storm event hours
20. Total rainfall (in inches) inches
21. Number of hours between the start of
storm measured and end of the previous
measurable storm event:
hours
PART B: GENERAL MONITORING SAMPLE INFORMATION
Reset Form
PART D: MONITORING RESULTS
Parameters
Field
pH
O &G
(mg/L)
CBOD5
(mg/L)
COD
(mg/L)
TSS
(mg/L)
TKN
(mg/L)
Phosphorous,
Total
(mg/L)
Nitrate-
Nitrite Nitrogen
(mg/L)
22. Outfall 23. Time sample was collected
24. Results
25. Outfall 26. Time sample was collected
27. Results
28. Outfall 29. Time sample was collected
30. Results
31. Outfall 32. Time sample was collected
33. Results
34. Outfall 35. Time sample was collected
36. Results
37. Are there any additional results or pollutants sampled for,
not listed above, and included in the laboratory analysis report?
Yes, additional pollutants were
sampled and are included in the
laboratory report.
No, additional pollutants were not
sampled for.
PART E: CERTIFICATION STATEMENT
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 possibility of fine and imprisonment for knowing violations.
Signature of responsible corporate officer or duly authorized representative under 327 IAC 15-4-3(g).
Signature ____________________________________ Date
(month, day, year) ______________
APPENDIX A: SUPPLEMENTARY INFORMATION
Monitoring requirements
Each discharge outfall as listed on your approved Notice of Intent form, composed entirely of storm water and
allowable non-storm water run-off, shall be monitored annually. Within one (1) year of the original or renewal NOI
letter submittal and prior to implementation of the Strom Water Pollution Prevention Plan (SWP3), a permitted facility
shall sample and analyze the discharge from the outfall(s) identified in the approved NOI letter. The monitoring data
taken from this first year event shall be used by the permitted facility as an aid in developing and implementing the
SWP3. Subsequent annual sampling data shall be used to verify the effectiveness of the SWP3 and will aid your
facility with revising the SWP3 and implementation of additional Best Management Practices.
Each discharge outfall shall be monitored for any pollutant attributable to your facility’s industrial activity that is
reasonably expected to be present in the discharge.
Run-off events resulting from snow or ice melt should not be sampled and shall not be used to meet the minimum
annual monitoring requirements.
All grab samples must be collected from a discharge resulting from a measurable storm event at least seventy-two
(72) hours from the previous measurable storm event. Keep record and documentation of weather conditions.
Measurable storm event means a precipitation event which results in a total measured precipitation accumulation
equal to, or greater than, one-tenth (0.1) inch.
Reporting requirements
Permitted facilities are required to submit a storm water monitoring report and the required attachments annually.
Sampling data results shall be submitted to IDEM within thirty (30) days after laboratory analyses have been
completed. There shall be a minimum of three (3) months between reported sampling events. The analytical
techniques and results of all required analyses and measurements shall be submitted in concurrence with this form,
including a chain-of-custody.
If a permitted facility monitors a pollutant more frequently than annually, the results of such monitoring must be
reported as additional information in the annual report, such increased frequency must also be indicated in the
report.
Part A. Permit information
1. Enter the facility’s permit identification number as assigned by IDEM. If you do not know the permit
identification number, you can find it on the Notice of Sufficiency (NOS) Letter from IDEM responding
to your most recent Notice of Intent (NOI) application.
2-6. Enter the permitted Facility’s name, street address, city, county, and ZIP code.
7-9. Enter the contact person’s name, telephone number and e-mail address.
Part B. General monitoring sample Information
10. Enter the sample year, or year in which this report is satisfying the annual monitoring report
requirements. For example, if the facility is conducting their first sample, then their sample year is Year
one.
11. Enter the laboratory name your facility chose to conduct the analyses of the collected storm water
sample.
12. Enter the date the laboratory completed the analyses.
13. Check the yes or no box. By checking the Yes box, you are certifying that the laboratory report and
chain-of-custody has been attached. The laboratory report must be attached to satisfy your annual
sampling requirements.
Part C. Field sampling data
14. Enter the name of the person collecting the storm water discharge sample.
15. Enter the name of the outfall(s) sampled during this storm event. Outfall(s) shall be listed by name, as
they were on your NOI Letter. Annual storm water samples shall be collected during the same
measurable storm event.
16. Describe the type of sampled outfall(s). A storm water outfall conveys storm water and was previously
defined in you NOI Letter. A type may be described as a pipe, channel, seepage point, grass swale,
any ditches, etc.
17. Enter the date the storm water discharge sample was collected.
18. Enter the start time, or the time of the start of the discharge.
19. Enter the duration in hours of the storm event sampled.
20. Enter the total accumulated rainfall amount for the sampled storm event. This information may be
obtained from an on-site rain gauge or by accessing the National Oceanic Atmospheric Administration
(NOAA) Web site at http://www.noaa.gov/
.
21. Enter the amount of time, in hours, from the end of the last measurable storm event to the start of the
storm event being sampled. Measurable storm event means a precipitation event which results in a
total measured precipitation accumulation equal to or greater than, one-tenth (0.1) inch.
Part D: Monitoring results
Permitted facilities are required to sample for the following eight parameters:
Field pH, O & G – Oil and Grease, CBOD5 – Carbonaceous biochemical oxygen demand, COD –
Chemical oxygen demand, TSS – Total suspended solids, TKN – Total Kjeldahl nitrogen, Total
Phosphorous, Nitrate plus nitrite nitrogen, pH (measurement shall be obtained in the field)
Analytical and sampling methods used must meet the requirements of 327 IAC 5-2-13(d)(1) and
327 IAC 5-2-13(d)(2).
22- 36. Enter the outfall and enter the exact time the storm water discharge sample was collected at each
outfall. Then enter the laboratory results of the required parameters in the coinciding results column.
The pH measurement must be taken at the time the grab sample is collected and by using a pH meter
that has been properly calibrated according to manufacturer’s specifications and provides results
displayed in numeric units. A color comparison analysis for pH is not acceptable. Any additional
parameters sampled for should be included in the annual report comparison table, as well as on the
attached laboratory report. If storm water is sampled more frequently than required, the results of such
monitoring must be reported as additional information in the annual report.
37. Check the box which most appropriately matches your site. Check Yes if your facility submitted
sampling results for additional pollutants, which may be present.
