Form CEM-2061T "Notice of Discharge Report - Lake Tahoe Hydrologic Unit Stormwater Sample Field Test Report/Receiving Water Monitoring Report" - California

What Is Form CEM-2061T?

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 May 1, 2015;
  • 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-2061T 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-2061T "Notice of Discharge Report - Lake Tahoe Hydrologic Unit Stormwater Sample Field Test Report/Receiving Water Monitoring Report" - California

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NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 1 of 5
CEM-2061T (REV 05/2015)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT RESIDES IN THE LAKE TAHOE HYDROLOGIC UNIT AND IS REGULATED
UNDER ORDER NO. R6T-2011-0019, NPDES NO. CAG616002.
Submitted by contractor (print and sign name)
Date
Notice of Discharge General Information
Location
Date discharge discovered
Discharge type
Exceedance of applicable water quality standard
Stormwater
Turbidity (NEL)
Discharge identified
Discharge discovered
Discharge samples
by visual site
by contractor during
taken?
inspection?
daily work?
Authorized non-stormwater
pH (NAL)
YES
YES
YES
Non-authorized non-stormwater
NO
NO
NO
Discharge identified by Regional
Discharge identified by State
Date and time water pollution control manager notified of discharge
Water Quality Control Board?
Water Resources Control Board?
YES
YES
Date and time resident engineer notified of discharge
NO
NO
Storm Event Information
Complete this section for stormwater discharges
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
Date
Hours : Minutes.
inches
inches
Time
Time
Notice of Discharge Information
Photographs
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
Implementation schedule for additional BMPs
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.
NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 1 of 5
CEM-2061T (REV 05/2015)
PROJECT INFORMATION NAME AND SITE ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFIER NUMBER
WDID NUMBER
CONTRACTOR NAME AND ADDRESS
PROJECT RESIDES IN THE LAKE TAHOE HYDROLOGIC UNIT AND IS REGULATED
UNDER ORDER NO. R6T-2011-0019, NPDES NO. CAG616002.
Submitted by contractor (print and sign name)
Date
Notice of Discharge General Information
Location
Date discharge discovered
Discharge type
Exceedance of applicable water quality standard
Stormwater
Turbidity (NEL)
Discharge identified
Discharge discovered
Discharge samples
by visual site
by contractor during
taken?
inspection?
daily work?
Authorized non-stormwater
pH (NAL)
YES
YES
YES
Non-authorized non-stormwater
NO
NO
NO
Discharge identified by Regional
Discharge identified by State
Date and time water pollution control manager notified of discharge
Water Quality Control Board?
Water Resources Control Board?
YES
YES
Date and time resident engineer notified of discharge
NO
NO
Storm Event Information
Complete this section for stormwater discharges
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
Date
Hours : Minutes.
inches
inches
Time
Time
Notice of Discharge Information
Photographs
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
Implementation schedule for additional BMPs
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.
NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 2 of 5
CEM-2061T (REV 05/2015)
Notice of Discharge Information (continued)
Maintenance or repair of BMPs
Implementation schedule for BMPs maintenance or repair
Other required corrective actions
Implementation schedule for corrective actions
Summary of actions taken to reduce the pollutants causing or contributing to the water quality standard exceedance
Sampling and Analysis Information
Required when discharge samples are taken. Attach lab results report if applicable.
Are discharge samples taken?
YES
NO
YES
NO
RESULTS PENDING
Is lab results report attached?
If applicable, provide lab information: lab name, contract name, date samples sent, attach a copy of chain of custody, etc.
NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 3 of 5
CEM-2061T (REV 05/2015)
Stormwater Samples Analysis
Date of sampling
Sample location identification number
Date of analysis
Sample analyzed by (signature)
Samples to be analyzed for parameters
Turbidity
Sample analyzed by (print name)
pH
Analyzer phone number
Other
(
)
Other
Company
Field Turbidity Analysis Information
Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
Field pH Analysis Information
pH Meter Manufacturer
Model Number
Serial Number
Calibration Date
Analytical Method
Method Reporting Unit
Method Detection Limit
NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 4 of 5
CEM-2061T (REV 05/2015)
Notice of Discharge 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 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)
Date
Water Pollution Control Manager (signature)
For Caltrans Use
Accepted by Resident Engineer (name)
Date
Resident Engineer( signature)
Discharge reported orally to the Lahontan RWQCB within 24 hours of
Date called Lahontan RWQCB
Resident engineer initials
discovery?
YES
NO
Electronic submittal of NEL exceedance sample results to Lahontan
Date report submitted
Resident engineer initials
RWQCB and SMARTS within 5 business days?
YES
NO
NOTICE OF DISCHARGE REPORT - LAKE TAHOE HYDROLOGIC UNIT
STORMWATER SAMPLE FIELD TEST REPORT/RECEIVING WATER MONITORING REPORT
Page 5 of 5
CEM-2061T (REV 05/2015)
INSTRUCTIONS
General Information
Board (SWRCB), or Regional Water Quality Control Board (RWQCB) staff determines that storm water discharges,
authorized non-stormwater discharges, or nonauthorized, non-stormwater discharges are causing or contributing to an
exceedance of an applicable water quality standard.
occurred.
Construction Site Monitoring Program Guidance Manual.
Standard Methods for the Examination
of Water and Wastewater" (American Public Health Association).
Assurance Program Plan latest edition.
Form
Project Identifier Number
Caltrans projects starting July 1, 2010, will have a project identifier number. For projects without a number, write N/ A in the
field.
Contract Number/Co/RTE/PM
For encroachment permit projects write the local agency of private entity encroachment permit number in the contract
number field.
Storm Event Information
Leave section blank if box is checked for either authorized or non-authorized non-stormwater discharge.
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 activity that caused the discharge.
Sampling and Analysis Results
Leave this section blank if the 'no' box is checked for discharge samples taken.
Analytical results less than the method detection limit shall be reported as "less than the method detection limit."
Leave section blank if the 'no' box is checked for discharge samples taken.
A minimum of three daily samples are required to calculate the daily average for a qualifying rain event.
Sample pH reading must be done within 15 minutes of sample collection.
In the event that any daily average RWMT is exceeded, complete Form CEM-2062, "Numeric Action Level Exceedance
Report I Receiving Water Monitoring Trigger Report" and submit all storm event sampling results to the resident engineer
within six hours.
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