Form MTCE-0040 Facility Pollution Prevention Plan Maintenance Facility - California

Form MTCE-0040 is a California Department of Transportation form also known as the "Facility Pollution Prevention Plan Maintenance Facility". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download an up-to-date Form MTCE-0040 in PDF-format down below or look it up on the California Department of Transportation Forms website.

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FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
Prepared by, District Maintenance Stormwater Coordinator
Date
Name
Classification Title
Nature of Revision/New
Certification Revisions
Date
Name
Classification Title
Nature of Revision/New
+
FACILITY INFORMATION
Facility Name
District
EFIS Number
Site ID Number
Street Address
City
County
ZIP Code
Facility Acreage
Facility Elevation
Latitude
Longitude
Facility Phone
Regional Water Quality Control Boards (RWQCB)
2.0
Maintenance Facility Information
Are maintenance crews stationed at this facility?
YES
NO
Are maintenance vehicles stored or stationed at this facility?
YES
NO
2.2
Topological Features
Enter general description of facility flow directions and how stormwater drains on-site. Identify paved and unpaved
areas, sloped and vegetated surfaces in the facility.
2.3
Environmental Areas and Surface Water Bodies
Enter a general description of any Environmentally Sensitive Area (ESA), Area of Special Biological Significance
(ASBS), wetlands, and other 303d listed or surface water bodies near the facility or to which the facility drains. Provide
approximate distance in miles or yards and general direction of water bodies relative to the site. 303d, TMDL and ASBS
can be found here:
http://svctenvims.dot.ca.gov/wqpt/wqpt.aspx
2.4
Water Supply and Site Wells
Is water supplied to the site?
YES
NO
Are there any injection or monitoring wells located at this facility?
YES
NO
2.5
Stormwater Conveyance and TBMPs
Enter a general description of the stormwater conveyance and where the system drains. Include a description of
ditches, channels and drain inlets, where stormwater leaves the site. These locations shall be noted on the facility map.
Is a TBMP present?
YES
NO
OTHER
2.6
Wash Water Conveyance
Is there a pre-wash/or wash area at the facility?
YES
NO
Is there a decanting site located at the facility?
YES
NO
2.7
Sewage Conveyance
YES
NO
Is there a sewage conveyance for this facility?
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
Prepared by, District Maintenance Stormwater Coordinator
Date
Name
Classification Title
Nature of Revision/New
Certification Revisions
Date
Name
Classification Title
Nature of Revision/New
+
FACILITY INFORMATION
Facility Name
District
EFIS Number
Site ID Number
Street Address
City
County
ZIP Code
Facility Acreage
Facility Elevation
Latitude
Longitude
Facility Phone
Regional Water Quality Control Boards (RWQCB)
2.0
Maintenance Facility Information
Are maintenance crews stationed at this facility?
YES
NO
Are maintenance vehicles stored or stationed at this facility?
YES
NO
2.2
Topological Features
Enter general description of facility flow directions and how stormwater drains on-site. Identify paved and unpaved
areas, sloped and vegetated surfaces in the facility.
2.3
Environmental Areas and Surface Water Bodies
Enter a general description of any Environmentally Sensitive Area (ESA), Area of Special Biological Significance
(ASBS), wetlands, and other 303d listed or surface water bodies near the facility or to which the facility drains. Provide
approximate distance in miles or yards and general direction of water bodies relative to the site. 303d, TMDL and ASBS
can be found here:
http://svctenvims.dot.ca.gov/wqpt/wqpt.aspx
2.4
Water Supply and Site Wells
Is water supplied to the site?
YES
NO
Are there any injection or monitoring wells located at this facility?
YES
NO
2.5
Stormwater Conveyance and TBMPs
Enter a general description of the stormwater conveyance and where the system drains. Include a description of
ditches, channels and drain inlets, where stormwater leaves the site. These locations shall be noted on the facility map.
Is a TBMP present?
YES
NO
OTHER
2.6
Wash Water Conveyance
Is there a pre-wash/or wash area at the facility?
YES
NO
Is there a decanting site located at the facility?
YES
NO
2.7
Sewage Conveyance
YES
NO
Is there a sewage conveyance for this facility?
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
Table 3-1, Best Management Practices (BMP) Attachment C Reference Key
Table 3-1
Potential Pollutant Sources at the , Pollutants of Concern, Location, BMPs and BMP Reference
Pollutants of Concern
BMP Reference
Potential Pollutant Sources
Describe BMPs in Place
(Attachment C)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
Table 3-2
Non-Hazardous Materials
Map Location
Non-Hazardous Material
BMPs
(Attachment A)
+
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
3.4
Is there Hazardous Material stored at this Facility?
YES
NO
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
FACILITY POLLUTION PREVENTION PLAN MAINTENANCE FACILITY
Generate Full Report
MTCE-0040 (PILOT 08/2018)
4.2
Non-Stormwater Discharges Authorized by a Separate Permit
Other than the Caltrans statewide NPDES Permit, does this facility have a separate NPDES permit or Waste Discharge
YES
NO
Requirement (WDR)?
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.

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