Deq Form 605 006 – Fill Out and Use This PDF

See Page 4 for Instructions

Submission of this Comprehensive Site Compliance Evaluation Report, Part B, provides notice that the party identified in Section I of this form is not required to conduct Benchmark Monitoring for storm water discharges associated with industrial activities under the OPDES program. This Annual Comprehensive Site Compliance Evaluation Report is required for all authorized industrial facilities.

All Requested Information Must Be Provided On This Form (Part A) and the ACSCER Form (Part B).

See Instructions On Page 4 of The Form.

Section I.

OPDES Permit Authorization Number:

Section II. Facility Operator Information

Name: ______________________________________________ Phone:_________________________________

Address:______________________________________________________________________________________

City: __________________________________ County:_____________________ Zip Code:__________________

Section III. Facility Location

Name:_____________________________________________________ Phone:____________________________

Address: ______________________________________________________________________________________

City: _________________________________ County: _________________________ Zip Code:_______________

Latitude: ____________________________ Longitude:___________________________

Section IV. Certification

I certify under penalty of law that I have read and understand the requirements for filing this Comprehensive Site Compliance Evaluation Report, which is to be filed by March 1st of each year beginning in 2012.

This report is also to be retained as part of the SWP3 for at least three (3) years from the date permit coverage expires or is terminated and will be made available to any State or Federal Inspector visiting this facility. All records of actions taken in accordance with 4.10 of this permit as part of the Storm Water Pollution Prevention Plan will be retained for at least three (3) years from the date permit coverage expires or is terminated. 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 upon my inquiry of the person or persons who manage the system, or those persons directly involved in gathering the information, the information submitted is to the best of my knowledge and belief true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Print Name: ________________________________________________	Date:_________________________
Signature:__________________________________________________	Title:_________________________

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Part B. Page 2

If any significant spills or leaks occurred, did they result in more than the minimum amounts of material being discharged in storm water? Base your answer on your knowledge of the material you spilled or that leaked. The minimum amounts could vary with the nature (toxicity, oxygen demand, pH, etc.) of the spilled or leaked material from amounts left after normal "sweeping" type cleanup to the point at which even trace amounts left

after cleanup could cause an environmental problem.

Yes _____

No_____

No spills or leaks occurred______

Have all known spills or leaks been cleaned up or otherwise prevented from contaminating storm water that

would be discharged under the authority of this permit?

Yes _____ No_____

No spills or leaks occurred______

How many times did you visually monitor all your storm water discharges at all the facility outfalls during the reporting year, and document the condition of and around the outfalls, including flow dissipation measures to prevent scouring? (Count only those done in accordance with the procedures at Part 5.1 - Quarterly Visual Monitoring)

Yes _____ No_____

Number of Visual Monitoring _______

Would the results of your visual monitoring indicate that there are pollutants in your storm water discharges that are not adequately controlled by your current BMPs?

Yes _____ No_____

If the results of your visual monitoring indicated a potential problem, was it due to one or more of the following?

1.New pollutant source (including exposure of previously unexposed material).

2.Failure to implement or maintain an existing BMP.

3.Less than expected performance from a BMP.

4.No BMP was selected to deal with that problem.

5.N/A (No problems identified)

If your visual monitoring indicated a potential problem, what have you done to resolve the problem?

1.Eliminated exposure or pollutant source.

2.Modified existing BMPs.

3.Added a new BMP.

4.Plan to address problem by end of current reporting year.

5.Nothing planned.

6.N/A (No problems identified).

Did any analysis of any element tested during any previous discharge monitoring period exceed the numeric limitation value?

Yes _____ No_____

If your answer to the previous question was "Yes", please name the element and the test results.

Element	Test Results	Element	Test Results
_________________	_____________	_________________	_____________
_________________	_____________	_________________	_____________
_________________	_____________	_________________	_____________

Is there any required revisions to the SWP3 resulting from the inspection?

Yes _____ No_____

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Exhibit 5 Annual Comprehensive Site Compliance Evaluation Report - Instructions

Instructions for Completing the Annual Comprehensive Site Compliance Evaluation Report

Form 605-006, Storm Water Discharges Associated with Industrial Activity

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