"Annual Report Form for the Non-mining and Mining Multi-Sector General Permits" - Arizona

Annual Report Form for the Non-mining and Mining Multi-Sector General Permits is a legal document that was released by the Arizona Department of Environmental Quality - a government authority operating within Arizona.

Form Details:

  • Released on December 1, 2012;
  • The latest edition currently provided by the Arizona Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download "Annual Report Form for the Non-mining and Mining Multi-Sector General Permits" - Arizona

Download PDF

Fill PDF online

Rate (4.8 / 5) 56 votes
Page background image
ANNUAL REPORT FORM
for the Non-mining and Mining
Multi-Sector General Permits
Use this form for documenting results from the annual Comprehensive Facility Inspection, in accordance with Part 4.3 and Part 7.2 of
both permits. All permittees must complete an annual report form and keep a copy with the SWPPP. Permittees with facilities that
discharge to an impaired or outstanding Arizona water shall submit an annual report on or before July 15 (postmark date) during each
year until coverage is terminated (not when the permit expires) to the following address:
Arizona Department of Environmental Quality; Surface Water Section / Stormwater Program
1110 West Washington, 5415A-1; Phoenix, Arizona 85007
Faxed forms are not acceptable.
A. GENERAL INFORMATION
AZMSG–
1. AZPDES Authorization Number:
_________________________________
2. Facility Name: _________________________________________________________________________________________________________
3. Facility Physical Address:
Street: _______________________________________________________________________________________________________________
City: ______________________________________________________________ State: |___|___| Zip Code: ____________________________
4. Lead Inspector’s Name: ____________________________________________________ Title: ________________________________________
Additional Inspector’s Name(s): _____________________________________________
____________________________________________
5. Contact Person: __________________________________________________________ Title: ________________________________________
Telephone: ________________________________ Ext. ___________ E-mail: ___________________________________________________
/
/
6. Comprehensive Facility Inspection Date: |___|___|
|___|___|
|___|___|___|___|
B. GENERAL INSPECTION FINDINGS
1. Did this comprehensive facility inspection include all potential pollutant sources, including areas where industrial activity may be exposed to
stormwater?
____ YES
____ NO
If NO, explain 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.
Page 1 of 6
ANNUAL REPORT FORM
for the Non-mining and Mining
Multi-Sector General Permits
Use this form for documenting results from the annual Comprehensive Facility Inspection, in accordance with Part 4.3 and Part 7.2 of
both permits. All permittees must complete an annual report form and keep a copy with the SWPPP. Permittees with facilities that
discharge to an impaired or outstanding Arizona water shall submit an annual report on or before July 15 (postmark date) during each
year until coverage is terminated (not when the permit expires) to the following address:
Arizona Department of Environmental Quality; Surface Water Section / Stormwater Program
1110 West Washington, 5415A-1; Phoenix, Arizona 85007
Faxed forms are not acceptable.
A. GENERAL INFORMATION
AZMSG–
1. AZPDES Authorization Number:
_________________________________
2. Facility Name: _________________________________________________________________________________________________________
3. Facility Physical Address:
Street: _______________________________________________________________________________________________________________
City: ______________________________________________________________ State: |___|___| Zip Code: ____________________________
4. Lead Inspector’s Name: ____________________________________________________ Title: ________________________________________
Additional Inspector’s Name(s): _____________________________________________
____________________________________________
5. Contact Person: __________________________________________________________ Title: ________________________________________
Telephone: ________________________________ Ext. ___________ E-mail: ___________________________________________________
/
/
6. Comprehensive Facility Inspection Date: |___|___|
|___|___|
|___|___|___|___|
B. GENERAL INSPECTION FINDINGS
1. Did this comprehensive facility inspection include all potential pollutant sources, including areas where industrial activity may be exposed to
stormwater?
____ YES
____ NO
If NO, explain 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.
Page 1 of 6
3. Did this inspection identify any sources of stormwater or non-stormwater discharges not previously identified in your SWPPP?
_____ YES
_____ NO
If YES, describe the sources of stormwater or non-stormwater pollutants expected to be present in these discharges and any control measures in
place.
4. Did this inspection include a review of stormwater monitoring data to identify potential areas of concern for stormwater pollution?
_____ YES
_____ NO
_____ N/A, no monitoring performed
If YES, summarize the findings of that review and describe any additional inspection activities resulting from the 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 any corrective actions, as specified in Part 3 of the permit, during this reporting period, including any corrective actions identified
as a result of this annual comprehensive facility inspection?
_____ YES
_____ NO
Do you plan to take any corrective actions, as specified in Part 3 of the permit, including any corrective actions identified as a result of this annual
comprehensive facility inspection?
_____ YES
_____ NO
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.
Page 2 of 6
C. INDUSTRIAL ACTIVITY AREA-SPECIFIC FINDINGS
Complete one block for each industrial activity area where pollutants may be exposed to stormwater.
In reviewing each area, you must look for:
► 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 or 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 – Section D.)
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 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.)
Page 3 of 6
Copy this page for additional industrial activity areas 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 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 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 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.)
Page 4 of 6
D. CORRECTIVE ACTIONS
Complete this page for each specific condition requiring a corrective action. Copy this page for additional corrective actions.
1. Corrective Action #
|___|___| of |___|___| 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 conditions(s) triggering the need for this review.
____ Unauthorized release or discharge
____ Violation of a numeric effluent limitation guideline
____ Control measures inadequate to meet applicable water quality standards
____ Control measures inadequate to meet an adopted Waste Load Allocation
____ Control measures not properly operated or maintained
____ Change in facility operations necessitated change in control measures
____ Other (describe): _______________________________________________________________________________________________
4. Briefly describe the nature of the problem identified.
/
/
5. Date problem identified: |__|__|
|__|__|
|__|__|__|__|
6. How problem was identified:
____ Comprehensive facility inspection
____ Visual assessment
____ Quarterly routine facility inspection
____ Benchmark, numeric Effluent Limitation Guideline or other analytical monitoring
____ Notification by ADEQ, EPA or another Federal, State or local agency having stormwater program authority, or the operator of a regulated
MS4 receiving discharges from the facility (where applicable)
____ Other (describe): _______________________________________________________________________________________________
7. Description of corrective action(s) taken or to be taken to eliminate 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 to your SWPPP?
_____ YES
_____ NO
9. Date corrective action initiated: |___|___| / |___|___| / |___|___|___|___ |
10. Date corrective 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 facility inspection and describe any
remaining steps (including timeframes associated with each step) necessary to complete corrective action.
Page 5 of 6
Page of 6