Form CEM-2061 "Notice of Discharge Report" - California

What Is Form CEM-2061?

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 January 1, 2018;
  • 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-2061 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-2061 "Notice of Discharge Report" - California

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NOTICE OF DISCHARGE REPORT
Page 1 of 3
CEM-2061 (REV 01/2018)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
WDID NUMBER
DISCHARGE REPORT NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT SITE RISK LEVEL
Risk Level 1
Risk Level 2
Risk Level 3
N/A. WPCP
Submitted by contractor (print and sign name)
Date
A. Discharge Information
Discharge Location
Discharge Type
Stormwater
Authorized non-stormwater
Non-authorized non-stormwater
Other
Discharge identified by
Discharge samples taken?
YES
NO
Name:
If yes, complete Section E
Title:
Date/Time:
Date and time water pollution control manager notified of discharge:
Date and time resident engineer or district construction stormwater coordinator notified of discharge:
B. Discharge Information
Describe the discharge, based on a visual observation; estimate discharge quantities:
Photographs
YES
NO
Describe the source and the operation that cause the discharge:
YES
NO
Describe existing BMPs at the discharge location:
C. Field Response
Was the discharge eliminated?
YES
NO
Describe changes in operation and BMPs implemented to eliminate the discharge and control the source:
Corrective action plan and implementation schedule:
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.
NOTICE OF DISCHARGE REPORT
Page 1 of 3
CEM-2061 (REV 01/2018)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
WDID NUMBER
DISCHARGE REPORT NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT SITE RISK LEVEL
Risk Level 1
Risk Level 2
Risk Level 3
N/A. WPCP
Submitted by contractor (print and sign name)
Date
A. Discharge Information
Discharge Location
Discharge Type
Stormwater
Authorized non-stormwater
Non-authorized non-stormwater
Other
Discharge identified by
Discharge samples taken?
YES
NO
Name:
If yes, complete Section E
Title:
Date/Time:
Date and time water pollution control manager notified of discharge:
Date and time resident engineer or district construction stormwater coordinator notified of discharge:
B. Discharge Information
Describe the discharge, based on a visual observation; estimate discharge quantities:
Photographs
YES
NO
Describe the source and the operation that cause the discharge:
YES
NO
Describe existing BMPs at the discharge location:
C. Field Response
Was the discharge eliminated?
YES
NO
Describe changes in operation and BMPs implemented to eliminate the discharge and control the source:
Corrective action plan and implementation schedule:
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.
NOTICE OF DISCHARGE REPORT
Page 2 of 3
CEM-2061 (REV 01/2018)
DISCHARGE REPORT NUMBER
D. Assessment of Discharge
Discussion of the discharge event: how, why, whether the discharge was preventable, etc., who participated (required: WPC Manager, RE,
contractor's field superintendent)?
Future corrective actions to minimize or eliminate (provide a schedule and list responsible parties):
Were quantities estimated in Section B corrected by field measurements?
E. Sampling and Analysis Results
Required when discharge samples are taken. Attach CEM-2052 or lab results report.
Are discharge samples taken?
YES
NO
Is CEM-2052 attached?
YES
NO
N/A
Is lab results report attached?
YES
NO
RESULTS PENDING
If applicable, provide lab information: lab name, contract name, date samples sent, attach a copy of chain of custody, etc.
F. 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 assure 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 persons 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)
WPC Manager Phone Number
Water Pollution Control Manager (signature)
Date
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.
NOTICE OF DISCHARGE REPORT
Page 3 of 3
CEM-2061 (REV 01/2018)
DISCHARGE REPORT NUMBER
For Caltrans Use
Accepted by Resident Engineer (name)
Date
Resident Engineer (signature)
Discharge reported by telephone or email to the Regional Water
Date discharge reported to RWQCB Reported by
Quality Control Board (RWQCB)?
A. Immediately and no later than 2 hours
YES
NO
after discovery (sewage discharging)?
B. Within 24 hours (project specific)?
YES
NO
C. As soon as possible but within 48 hours?
YES
NO
Notice of Discharge Report submitted to RWQCB within 14 days
Resident Engineer or DCSWC initials
Date report submitted to RWQCB
(3 days for District 7 and District 11)?
A. Within 24 hours (sewage discharge)?
YES
NO
B. Within 14 days?
YES
NO
C. Within
days (project specific)?
YES
NO
Instructions
GENERAL INFORMATION
This form is required for compliance with provisions in Section E.2.c, "Monitoring and Discharge Characterization Requirements," of the
National Pollutant Discharge Elimination System (NPDES) Permit Statewide Storm Water Permit and Waste Discharge Requirements
(WDRs) for the State of California, Department of Transportation, Order No. 2012-0011-DWQ, NPDES No. CAS000003.
This form is to be completed when the contractor, Caltrans, State Water Resources Control Board, or Regional Water Quality Control Board
staff determines that stormwater discharges, authorized non-stormwater discharges, or non-authorized, non-stormwater discharges are
causing or contributing to an exceedance of an applicable water quality standard.
This form is appropriate when there is evidence of a discharge that occurred outside of business hours where no sampling occurred.
This form is appropriate when there is a discharge of AC grindings; concrete debris, rubble, or fines; dry materials; construction wastes; or,
contaminated soils or sediment.
When a discharge occurs, Section C is used to describe the maintenance or repair of BMPs that were done and Section D is used to
describe BMPs that will be implemented in the future.
Water quality standards are contained in the Statewide Water Quality Control Plan or applicable Regional Water Quality Control Boards
(RWQCBs) Basin Plan.
Sampling guidance is found in the current edition of the Construction Site Monitoring Program Guidance Manual.
If sampling is done, effluent samples must be collected.
Include a copy of the completed form in the project Storm Water Pollution Prevention Plan (SWPPP) files.
FORM
Contract Number/Co/Rte/PM
For encroachment permit projects, write the local agency or private entity encroachment permit number in the contract number field.
Discharge Information
Do not leave any subsection blank. Caltrans permit specifically requires Caltrans to submit the information in this section to RWQCBs.
For non-stormwater discharges, describe the construction operation or activity that caused the discharge.
Field Response
Corrective action plan must include a description of maintenance or repair for existing BMPs and an implementation schedule for future
BMP changes or implementation.
Sampling and Analysis Results
Leave this section blank if the no box is checked for discharge samples taken.
Notice of Discharge Report Certification
For instruction on reporting timelines, see Section 9.4, Noncompliance Reporting, of Statewide Stormwater Management Plan, May 2003.
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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