Form CEM-2062T "Numeric Action Level Exceedance Report - Lake Tahoe Hydrologic Unit" - California

What Is Form CEM-2062T?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the California Department of Transportation;
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  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-2062T by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE
REPORT — LAKE TAHOE HYDROLOGIC UNIT
CEM-2062T (REV 06/2019)
Page 1 of 4
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
Project Risk Level: N/A
Project resides in the Lake Tahoe Hydrologic Unit and
is regulated under Order No. R6T-2016-0010, NPDES
No. CAG616002
SUBMITTED BY CONTRACTOR (PRINT AND SIGN NAME)
DATE
Numeric Action Level Exceedance Information
Location
Parameter Violation
pH
Sample location Identification number
Date of sampling
Samples collected by
Date of analysis
Samples analyzed by
Date and time water pollution control manager notified of results
Analyzer phone number
Date and time resident engineer notified of results
Sample Collection
Storm Event Precipitation
Sample Identification
Analysis (
)
Time
Amount at Sample Time
Analysis daily average:
Analysis Information
Meter manufacturer
Model number
Serial number
Calibration date
Analytical method
Method reporting unit
Method detection limit
Note: Meter calibration information available in the SWPPP files.
Storm Event Information
Start of storm event
End of storm event
Duration of storm event
Storm event precipitation
Storm event precipitation
amount recorded from
amount recorded from
site rain gauge
governmental rain gauge
Date
Date
Hours : Minutes
inches
inches
Time
Time
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE
REPORT — LAKE TAHOE HYDROLOGIC UNIT
CEM-2062T (REV 06/2019)
Page 1 of 4
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
Project Risk Level: N/A
Project resides in the Lake Tahoe Hydrologic Unit and
is regulated under Order No. R6T-2016-0010, NPDES
No. CAG616002
SUBMITTED BY CONTRACTOR (PRINT AND SIGN NAME)
DATE
Numeric Action Level Exceedance Information
Location
Parameter Violation
pH
Sample location Identification number
Date of sampling
Samples collected by
Date of analysis
Samples analyzed by
Date and time water pollution control manager notified of results
Analyzer phone number
Date and time resident engineer notified of results
Sample Collection
Storm Event Precipitation
Sample Identification
Analysis (
)
Time
Amount at Sample Time
Analysis daily average:
Analysis Information
Meter manufacturer
Model number
Serial number
Calibration date
Analytical method
Method reporting unit
Method detection limit
Note: Meter calibration information available in the SWPPP files.
Storm Event Information
Start of storm event
End of storm event
Duration of storm event
Storm event precipitation
Storm event precipitation
amount recorded from
amount recorded from
site rain gauge
governmental rain gauge
Date
Date
Hours : Minutes
inches
inches
Time
Time
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE
REPORT — LAKE TAHOE HYDROLOGIC UNIT
CEM-2062T (REV 06/2019)
Page 2 of 4
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Exceedance Location Information
Visual observation of location
Photographs
Yes
No
The nature and cause of the water quality standard exceedance, base on a visual observation of the discharge location
Yes
No
Additional BMPs that will be implemented to prevent or reduce pollutants causing or contributing to exceedance of a water quality standard
Implementation schedule for additional BMPs
BMPs that will be maintained or repaired to prevent or reduce pollutants causing or contributing to exceedance of water quality standard
Implementation schedule for BMPs maintenance or repair
Other required corrective actions
Implementation schedule for corrective actions
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE
REPORT — LAKE TAHOE HYDROLOGIC UNIT
CEM-2062T (REV 06/2019)
Page 3 of 4
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Additional Information
Run-on samples taken?
Run-on sample identification
Yes
No
Numeric Action Level Exceedance 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 ensure 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, to the best of my knowledge and belief,
the information submitted is true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations.
Water Pollution Control Manager (name)
Date
Water Pollution Control Manager (signature)
Resident Engineer (name)
Date
Resident Engineer (signature)
Was Numeric Action Level exceedance reported by phone or in person
Date reported
Resident engineer initials
to the Lahontan Regional Water Quality Control Board within 24 hours?
Yes
No
All storm event sampling results submitted to State Water Board
Date input
Resident engineer initials
SMARTS database within 5 days after the conclusion of the storm event?
Yes
No
Notice of Discharge Reporting
Discharge reported by telephone or email to the Resident Engineer
Date discharge reported to RWQCB Resident engineer initials
within 6 hours of discovery?
Yes
No
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE
REPORT — LAKE TAHOE HYDROLOGIC UNIT
CEM-2062T (REV 06/2019)
Page 4 of 4
Instructions
General Information
This form is required for compliance with provisions for Numeric Action Level (NAL) Exceedance Report in the National Pollutant
Discharge Elimination System (NPDES) General Permit for Storm Water Discharges Associated With Construction and Land
Disturbance Activities, Lake Tahoe Hydrologic Unit Permit Order No. R6T-2016-0010, NPDES No. CAG616002.
Sampling guidance is found in the Caltrans, Construction Site Monitoring Program Guidance Manual, latest edition
Lahontan Regional Water Quality Control Board has the authority to require the submittal of an NAL Exceedance Report, for pH.
Include a copy of the completed form in the project Storm Water Pollution Prevention Plan (SWPPP) files.
Form
Contract Number/Co/Rte/PM
For local agency encroachment permit projects, write the encroachment permit number in the Contract Number field.
Project Identifier Number
Caltrans projects starting July 1, 2010, will have a Project Identifier Number (PIN). For projects without a PIN, write N/A in the field.
Storm Event Precipitation Amount at Sample Time
At time of sample collection, record amount of precipitation from onsite rain gauge.
Analysis Results
Analytical results that are less than the method detection limit shall be reported as "Less than the method detection limit."
Qualifying Rain Event Daily Average Analysis Result
A minimum of 3 daily samples is required to calculate the daily average for a qualifying rain event.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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