Form CEM-2062 "Numeric Action Level Exceedance Report" - California

What Is Form CEM-2062?

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-2062 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-2062 "Numeric Action Level Exceedance Report" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE REPORT
Page 1 of 4
CEM-2062 (REV 7/2014)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT SITE RISK LEVEL
Risk Level 2
Risk Level 3
Submitted by contractor (print and sign name)
Date
Numeric Action Level Exceedance Information: Attach CEM-2052
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
Hours : Minutes
Date
inches
inches
Time
Time
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
NUMERIC ACTION LEVEL EXCEEDANCE REPORT
Page 1 of 4
CEM-2062 (REV 7/2014)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT SITE RISK LEVEL
Risk Level 2
Risk Level 3
Submitted by contractor (print and sign name)
Date
Numeric Action Level Exceedance Information: Attach CEM-2052
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
Hours : Minutes
Date
inches
inches
Time
Time
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
NUMERIC ACTION LEVEL EXCEEDANCE REPORT
Page 2 of 4
CEM-2062 (REV 7/2014)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Exceedance Location Information
Photographs
Visual observation of location
YES
NO
The nature and cause of the water quality standard exceedance, based on a visual observation of the discharge location
YES
NO
BMPs currently installed at the location of the discharge
YES
NO
Additional BMPs that will be implemented to prevent or reduce pollutants causing or contributing to exceedance of a water quality standard
YES
NO
Implementation schedule for additional BMPs
Maintenance or repair of BMPs
YES
NO
Implementation schedule for BMPs maintenance or repair
Other required corrective actions
YES
NO
Implementation schedule for corrective actions
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE REPORT
Page 3 of 4
CEM-2062 (REV 7/2014)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Numeric Action Level Exceedance Report 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 person 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
For Caltrans Use
Resident engineer name
Date
Resident engineer signature
Numeric Action Level Exceedance Report submitted to State Board SMARTS
Date input
Resident engineer initials
database within 24 hours after NAL exceedance was identified?
YES
NO
All storm event sampling results submitted to State Water Board SMARTS database
Date input
Resident engineer initials
within 10 days after the conclusion of the storm event?
YES
NO
Notice of Discharge Reporting
Discharge reported by telephone or email to the Regional Water Quality Control Board
Date discharge reported to RWQCB
Resident engineer intials
(RWQCB) within 48 hours of discovery?
YES
NO
Notice of Discharge Report submitted to RWQCB within 14 days (3 days for District 7
Date report submitted to RWQCB
Resident engineer intials
and District 11)?
YES
NO
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
NUMERIC ACTION LEVEL EXCEEDANCE REPORT
Page 4 of 4
CEM-2062 (REV 7/2014)
Instructions
General Information
This form is required for compliance with provisions for Numeric Action Level (NAL) Exceedance Report in Section I of Attachment D or 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.
Sampling guidance is found in the Caltrans, Construction Site Monitoring Program Guidance Manual, latest edition.
In the event that any daily average effluent sample analysis result exceeds an applicable NAL, submit all storm event sampling results to the State
Regional Water Quality Control Board (RWQCB) no later than 10 days after the conclusion of the storm event.
RWQCBs have the authority to require the submittal of an NAL Exceedance Report.
.
You may submit an NAL Exceedance Report to RWQCB instead of a Notice of Discharge Report.
Include a copy of the completed form in the project Storm Water Pollution Prevention Plan (SWPP) 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 three daily samples is required to calculate the daily average for a qualifying rain event.