ADEM Form 25 "ADEM Npdes Construction Stormwater Noncompliance Notification Report" - Alabama

What Is ADEM Form 25?

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

Form Details:

  • Released on November 1, 2011;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 25 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 25 "ADEM Npdes Construction Stormwater Noncompliance Notification Report" - Alabama

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ADEM NPDES CONSTRUCTION STORMWATER NONCOMPLIANCE NOTIFICATION REPORT
RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES
WILL BE RETURNED AND MAY RESULT IN APPROPRIATE COMPLIANCE ACTION BY THE DEPARTMENT.
IF SPACE IS
INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. PLEASE TYPE OR PRINT IN INK.
Complete this form, attach additional information as necessary, and send report to ADEM.
Item I.
Permittee Name
Facility/Site Name
S
County
Facility Contact and Title
NPDE
ALR10
Facility Street Address or Location Description
City
State
Zip
Phone Number
Fax Number
E-Mail Address
Item II.
DESCRIPTION OF NONCOMPLIANCE OR NONCOMPLIANT DISCHARGE:
Item III.
INSPECTION AND BMP CERTIFICATION REPORT(S), ANY PHOTOGRAPHS, AND ANY SAMPLING RESULTS ARE ATTACHED. IF
NOT, PLEASE EXPLAIN:
Item IV.
CAUSE OF NONCOMPLIANCE:
Item V.
PERIOD OF NONCOMPLIANCE: (Include exact date(s) and time(s) or, if not corrected, the anticipated time the noncompliance is expected to
continue):
Item VI.
DESCRIPTION OF STEPS TAKEN AND/OR BEING TAKEN (PROPOSED COMPLIANCE SCHEDULE) TO REDUCE AND/OR ELIMINATE
THE NONCOMPLYING DISCHARGE, REPAIR/REPLACE/UPGRADE BMPs, AND TO PREVENT ITS RECURRENCE:
“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 certify that this form has not been altered, and if
copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”
Name & Designation of QCP
Signature
Date
Name & Title of Permittee Responsible Official
Signature
Date
ADEM Form 25 11/11
Page 1 of 1
ADEM NPDES CONSTRUCTION STORMWATER NONCOMPLIANCE NOTIFICATION REPORT
RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES
WILL BE RETURNED AND MAY RESULT IN APPROPRIATE COMPLIANCE ACTION BY THE DEPARTMENT.
IF SPACE IS
INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS NECESSARY. PLEASE TYPE OR PRINT IN INK.
Complete this form, attach additional information as necessary, and send report to ADEM.
Item I.
Permittee Name
Facility/Site Name
S
County
Facility Contact and Title
NPDE
ALR10
Facility Street Address or Location Description
City
State
Zip
Phone Number
Fax Number
E-Mail Address
Item II.
DESCRIPTION OF NONCOMPLIANCE OR NONCOMPLIANT DISCHARGE:
Item III.
INSPECTION AND BMP CERTIFICATION REPORT(S), ANY PHOTOGRAPHS, AND ANY SAMPLING RESULTS ARE ATTACHED. IF
NOT, PLEASE EXPLAIN:
Item IV.
CAUSE OF NONCOMPLIANCE:
Item V.
PERIOD OF NONCOMPLIANCE: (Include exact date(s) and time(s) or, if not corrected, the anticipated time the noncompliance is expected to
continue):
Item VI.
DESCRIPTION OF STEPS TAKEN AND/OR BEING TAKEN (PROPOSED COMPLIANCE SCHEDULE) TO REDUCE AND/OR ELIMINATE
THE NONCOMPLYING DISCHARGE, REPAIR/REPLACE/UPGRADE BMPs, AND TO PREVENT ITS RECURRENCE:
“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 certify that this form has not been altered, and if
copied or reproduced, is consistent in format and identical in content to the ADEM approved form. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”
Name & Designation of QCP
Signature
Date
Name & Title of Permittee Responsible Official
Signature
Date
ADEM Form 25 11/11
Page 1 of 1