Form CEM-2070 "Swppp/Wpcp Annual Certification of Compliance" - California

What Is Form CEM-2070?

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 December 1, 2013;
  • 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-2070 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-2070 "Swppp/Wpcp Annual Certification of Compliance" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SWPPP/WPCP ANNUAL CERTIFICATION OF COMPLIANCE
Page 1 of 4
CEM-2070 (REV 12/2013)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
SWPPP PROJECT SITE RISK LEVEL
N/A. WPCP
Risk Level 1
Risk Level 2
N/A. Project resides in the Lake Tahoe Hydrologic Unit
and is regulated under Order No. R6T-2011-0019,
Risk Level 3
NPDES No. CAG616002.
Stormwater Pollution Prevention Plan (SWPPP)/Water Pollution Control Program (WPCP)
Annual Certification of Compliance
Water Pollution Control Manager Certification
This certification for the project site is based on an inspection of the project site conducted on (date)
I certify based on my inspection of the project site that:
Yes
No
Water pollution control measures are being implemented in accordance with the SWPPP or WPCP approved for the project,
including approved SWPPP/WPCP amendments.
Yes
No
The project site and activities thereon are in compliance with the Caltrans Statewide NPDES Permit No. CAS000003, the
NPDES General Permit for Stormwater Discharges Associated with Construction and Land Disturbance Activities, Order No.
2009-0009-DWQ, NPDES Permit No. CAS000002, or Order No. R6T-2011-0019, NPDES No. CAG-616002, whichever is
applicable.
Contractor Water Pollution Control Manager signature
Date
Contractor Water Pollution Control Manager name
Phone number
Contractor Annual Certification of Compliance
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 gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the
system or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that significant penalties exist for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Contractor signature
Date
Contractor name
Phone number
Title
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
SWPPP/WPCP ANNUAL CERTIFICATION OF COMPLIANCE
Page 1 of 4
CEM-2070 (REV 12/2013)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
SWPPP PROJECT SITE RISK LEVEL
N/A. WPCP
Risk Level 1
Risk Level 2
N/A. Project resides in the Lake Tahoe Hydrologic Unit
and is regulated under Order No. R6T-2011-0019,
Risk Level 3
NPDES No. CAG616002.
Stormwater Pollution Prevention Plan (SWPPP)/Water Pollution Control Program (WPCP)
Annual Certification of Compliance
Water Pollution Control Manager Certification
This certification for the project site is based on an inspection of the project site conducted on (date)
I certify based on my inspection of the project site that:
Yes
No
Water pollution control measures are being implemented in accordance with the SWPPP or WPCP approved for the project,
including approved SWPPP/WPCP amendments.
Yes
No
The project site and activities thereon are in compliance with the Caltrans Statewide NPDES Permit No. CAS000003, the
NPDES General Permit for Stormwater Discharges Associated with Construction and Land Disturbance Activities, Order No.
2009-0009-DWQ, NPDES Permit No. CAS000002, or Order No. R6T-2011-0019, NPDES No. CAG-616002, whichever is
applicable.
Contractor Water Pollution Control Manager signature
Date
Contractor Water Pollution Control Manager name
Phone number
Contractor Annual Certification of Compliance
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 gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the
system or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that significant penalties exist for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Contractor signature
Date
Contractor name
Phone number
Title
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
SWPPP/WPCP ANNUAL CERTIFICATION OF COMPLIANCE
Page 2 of 4
CEM-2070 (REV 12/2013)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Required for Private Entity Administered Projects
Private Entity Legally Responsible Person Annual Certification of Compliance
I certify that the project is in compliance with the project site approved Stormwater Pollution Prevention Plan or Water Pollution Control Program including
approved amendments. The project site and activities thereon are in compliance with the Caltrans Statewide NPDES Permit No. CAS000003, the NPDES
General Permit for Stormwater Discharges Associated with Construction and Land Disturbance Activities, Order No. 2009-0009-DWQ, NPDES Permit No.
CAS000002, or Order No. R6T-2011-0019, NPDES No. CAG-616002, whichever is applicable.
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 gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the
system or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that significant penalties exist for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Legally responsible person signature
Date
Legally responsible person name
Phone number
Title
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SWPPP/WPCP ANNUAL CERTIFICATION OF COMPLIANCE
Page 3 of 4
CEM-2070 (REV 12/2013)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
Resident Engineer Approval of Annual Certification of Compliance
An inspection of the project site for annual certification of compliance was
Annual Certification of Compliance project site inspection conducted by
conducted on (date)
I certify that I, or personnel acting under my direction and supervision, have inspected the project site and find the following:
Yes
No
Water pollution control measures are being implemented in accordance with the SWPPP or WPCP approved for the project,
including approved SWPPP/WPCP amendments.
Yes
No
The project site and activities thereon are in compliance with the Caltrans Statewide NPDES Permit No. CAS000003, the
NPDES General Permit for Stormwater Discharges Associated with Construction and Land Disturbance Activities, Order No.
2009-0009-DWQ, NPDES Permit No. CAS000002, or Order No. R6T-2011-0019, NPDES No. CAG-616002, whichever is
applicable.
The box above is checked "no" based on the project site annual certification inspection, and the following corrective actions are necessary for the project to be in
compliance with SWPPP/WPCP or NPDES Permits
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 gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the
system or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and
complete. I am aware that significant penalties exist for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Resident engineer signature
Date of approval
Resident engineer name
Phone number
Required for Local Agency or Private Entity-Administered Project
Caltrans Oversight Engineer's Concurrence With Annual Certification of Compliance
I, or personnel acting under my direction and supervision, have reviewed this Annual Certification of Compliance and concur that the project is in compliance with
SWPPP or WPCP approved for the project, including approved SWPPP/WPCP amendments and applicable NPDES Permits.
Oversight engineer signature
Date of concurrence
Oversight engineer name
Phone number
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SWPPP/WPCP ANNUAL CERTIFICATION OF COMPLIANCE
Page 4 of 4
CEM-2070 (REV 12/2013)
Instructions
General Information
Projects with either a Stormwater Pollution Prevention Plan (SWPPP) or Water Pollution Control Program (WPCP) require an Annual Certification
of Compliance by July 15th of each year.
Document the project site inspection for annual certification on form CEM-2030, "Stormwater Site Inspection Report."
A legally responsible person (LRP) or a signatory approved by the LRP must certify the Stormwater Pollution Prevention Plan Annual Certification
of Compliance.
- For Caltrans, the LRP is the district director. The LRP may authorize the project resident engineer to be the approved signatory.
- For a local agency, the LRP is either a principal executive officer or ranking elected official. The local agency's LRP may authorize the project
resident engineer to be the approved signatory. If the local agency's LRP has not approved the local agency's resident engineer to be an approved
signatory then the local agency's LRP must sign in the resident engineer signature box of the Annual Certification of Compliance.
- For a private entity performing work in the state right-of-way under an encroachment permit, the LRP must be one of the following:
• For a corporation—a responsible corporate officer.
• For a partnership or sole proprietorship—a general partner or the proprietor, respectively.
• The private entity's LRP may not authorize an approved signatory.
File a completed copy of this form in SWPPP/WPCP file category 20.70, Annual Certification of Compliance.
This form is used for Annual Certification as well as replaces form CEM-2001.
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.
WDID Number
For projects that have Water Pollution Control Program, enter "WPCP" in this field.
SWPPP Projects Site Risk Level
Check the box for the appropriate SWPPP risk level, or N/A for projects residing in the Lake Tahoe Hydrologic Unit, or N/A for projects that have Water Pollution
Control Program.
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