Form CEM-2052 "Stormwater Sample Field Text Report/Receiving Water Monitoring Report" - California

What Is Form CEM-2052?

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 July 1, 2014;
  • The latest edition provided by the California Department of Transportation;
  • 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 fillable version of Form CEM-2052 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-2052 "Stormwater Sample Field Text Report/Receiving Water Monitoring Report" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STORMWATER SAMPLE FIELD TEST REPORT/
RECEIVING WATER MONITORING REPORT
CEM-2052 (REV 7/2014)
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 SITE RISK LEVEL
N/A. WPCP
Risk Level 1
N/A. Project resides in the Lake Tahoe
Risk Level 2
Hydrologic Unit and is regulated under Order
No. R6T-2011-0019, NPDES No. CAG616002.
Risk Level 3
Submitted by contractor (print and sign name)
Date
Stormwater Samples Analysis
Date of sampling
Sample location identification number
Date of Analysis
Sample Analyzed By (signature)
Samples to be analyzed for parameters
Turbidity
Sampled Analyzed By (print name)
pH
Analyzer Phone Number
Other
(
)
Other
Company
Turbidity Analysis Information
Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
pH Analysis Information
pH Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STORMWATER SAMPLE FIELD TEST REPORT/
RECEIVING WATER MONITORING REPORT
CEM-2052 (REV 7/2014)
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 SITE RISK LEVEL
N/A. WPCP
Risk Level 1
N/A. Project resides in the Lake Tahoe
Risk Level 2
Hydrologic Unit and is regulated under Order
No. R6T-2011-0019, NPDES No. CAG616002.
Risk Level 3
Submitted by contractor (print and sign name)
Date
Stormwater Samples Analysis
Date of sampling
Sample location identification number
Date of Analysis
Sample Analyzed By (signature)
Samples to be analyzed for parameters
Turbidity
Sampled Analyzed By (print name)
pH
Analyzer Phone Number
Other
(
)
Other
Company
Turbidity Analysis Information
Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
pH Analysis Information
pH Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233,
ADA Notice
TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STORMWATER SAMPLE FIELD TEST REPORT/
RECEIVING WATER MONITORING REPORT
CEM-2052 (REV 7/2014)
Page 2 of 4
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Turbidity Calibration Record
Date
Standard Solution
Cal Standard
Notes
Initials
Initial Calibration
Re-Calibration
Drift Check
(NTU)
Solution
Time:
Time:
Time:
Expiration Date
Cal
Read
Cal
Read
Read
Acceptable Performance
pH Calibration Record
Buffer Solution Expiration Date: pH4.0 Date
pH7.0 Date
pH10.0 Date
Date
Electrode Number
Temperature at
Slope %
Re-check
Notes
Initials
Buffers Used for Calibration.
Calibration
Check those that apply.
pH 7.0
pH 4.0
pH 7.0
pH 10.0
Stormwater Sample Analysis Results - Discharge Points
Parameter Analysis *
Time
Time
Sample Identification
pH
NTU
Sample Value
Sample
Sample
and Units
Collected
Read
Qualifying Rain Event Daily Average Analysis Result
Stormwater Sample Analysis Results - Run-On Points
Parameter Analysis *
Time
Time
Sample Identification
pH
NTU
Sample Value
Sample
Sample
and Units
Collected
Read
Qualifying Rain Event Daily Average Analysis Result
* Complete and attach CEM-2058 to document calibration of instruments used to analyze these parameters.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STORMWATER SAMPLE FIELD TEST REPORT/
RECEIVING WATER MONITORING REPORT
CEM-2052 (REV 7/2014)
Page 3 of 4
Receiving Water Sample Analysis Results
Parameter Analysis *
Time
Time
Sample Identification
pH
NTU
SSC
Sample Value
Sample
Sample
and Units
Collected
Read
Qualifying Rain Event Daily Average Analysis Result
Review and Record Keeping
Test results entered into sampling and
Numeric action level exceedance?
Receiving water monitoring triggers
ATS NEL exceeded?
testing activity log?
exceeded?
Yes
Yes
Yes
Yes
No
No
No
No
* Complete and attach CEM-2058 to document calibration of instruments used to analyze these parameters.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STORMWATER SAMPLE FIELD TEST REPORT/
RECEIVING WATER MONITORING REPORT
CEM-2052 (REV 7/2014)
Page 4 of 4
Instructions
General Information
This form is required for compliance with provisions in Section I of Attachments C, D, and E of the National Pollutant Discharge Elimination System (NPDES)
General Permit for Storm Water Discharges Associated with Construction and Land Disturbance Activities, Order No. 2009-0009-DWQ, NPDES No.
CAS000002 and provisions of General Waste Discharge Requirements and National Pollutant Discharge Elimination System Permit for Lake Tahoe
Hydrologic Unit Order No. R6T-2011-0019 NPDES No. CAG616002.
The Caltrans, Construction Site Monitoring Program Guidance Manual, latest edition, contains sampling guidance.
Complete form CEM-2058 if other parameters are tested.
Sampling and sample preservation must be in accordance with the current edition of "Standard Methods for the Examination of Water and Wastewater"
(American Public Health Association).
Collect, maintain, and ship samples according to the State Water Resources Control Board's (SWRCB), Surface Water Ambient Monitoring Program's
(SWAMP) Quality Assurance Program Plan (QAPrP), latest edition.
Complete a separate stormwater sample field analysis report daily for each sampling location.
Include a copy of the completed form in the project Stormwater Pollution Prevention Plan files.
Form
Contract Number/Co/Rte/PM
For local agency encroachment permit projects, write the encroachment permit number in the Contract Number field.
Analysis Result
Analytical results less than the method detection limit must be reported as "less than the method detection limit".
Project Identifier Number
Caltrans projects starting July 1, 2010, will have a Project Identifier Number (PIN). For projects without a PIN, enter N/A in the field.
Qualifying Rain Event Daily Average Analysis Result
A minimum of three daily samples are required to calculate the daily average for a qualifying rain event.
Sample pH Analysis
Sample pH reading must be done within 15 minutes of sample collection.
Numeric Action Level Exceedance
In the event that any daily average effluent samples analysis results exceeds an applicable Numeric Action Level (NAL), complete form CEM-2062 "Numeric
Action Level Exceedance Report," and submit all storm event sampling results to the State Water Resources Control Board (SWRCB) no later than ten days after
the conclusion of the storm event.
Receiving Water Monitoring Trigger (RWMT) Exceedance
In the event that any daily average RWMT is exceeded, complete form CEM-2062, "Numeric Action Level Exceedance Report / Receiving Water Monitoring
Trigger Report" and submit all storm event sampling results to the resident engineer within six hours.
Add Exceptions Reasons:
N - No Run-off at time of inspection
O - Outside of normal business hours
U - Unsafe conditions/unsafe access
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