Msgp Annual Reporting Form - Alaska

The Alaska Department of Environmental Conservation has released this version of the "Msgp Annual Reporting Form" on January 1, 2015.

This form may be used by all Alaska residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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For Agency Use
Permit Tracking #: ___________________
Alaska Department of Environmental Conservation
MSGP Annual Reporting Form
Section I. General Information
Facility Name
APDES Permit Tracking Number
Facility Physical Address
Street
City
State
Zip Code
Alaska
Contact Person
Title
Phone
Email
Lead Inspector’s Name
Additional Inspector’s Name
Additional Inspector’s Name
Inspection Date
Section II. General Inspection Findings
1. As part of this comprehensive site inspection, did you inspect all potential pollutant
Yes
No
sources, including areas where industrial activity may be exposed to storm water?
If NO, describe why not:
Note: Complete Section III of this form for each industrial activity area inspected and included in your SWPPP or as newly defined, in Section II
parts 2 and 3 below, where pollutants may be exposed to storm water.
2. Did this inspection identify any storm water or non-storm water outfalls not previously
Yes
No
identified in your SWPPP?
If YES, for each location, describe the sources of those storm water and non-storm water discharges and any associated control
measures in place:
Page 1 of 6
MSGP Annual Report (Jan 2015)
For Agency Use
Permit Tracking #: ___________________
Alaska Department of Environmental Conservation
MSGP Annual Reporting Form
Section I. General Information
Facility Name
APDES Permit Tracking Number
Facility Physical Address
Street
City
State
Zip Code
Alaska
Contact Person
Title
Phone
Email
Lead Inspector’s Name
Additional Inspector’s Name
Additional Inspector’s Name
Inspection Date
Section II. General Inspection Findings
1. As part of this comprehensive site inspection, did you inspect all potential pollutant
Yes
No
sources, including areas where industrial activity may be exposed to storm water?
If NO, describe why not:
Note: Complete Section III of this form for each industrial activity area inspected and included in your SWPPP or as newly defined, in Section II
parts 2 and 3 below, where pollutants may be exposed to storm water.
2. Did this inspection identify any storm water or non-storm water outfalls not previously
Yes
No
identified in your SWPPP?
If YES, for each location, describe the sources of those storm water and non-storm water discharges and any associated control
measures in place:
Page 1 of 6
MSGP Annual Report (Jan 2015)
For Agency Use
Permit Tracking #: ___________________
3. Did this inspection identify any sources of storm water or non-storm water discharges not
Yes
No
previously identified in your SWPPP?
If YES, describe these sources of storm water or non-storm water pollutants expected to be present in these discharges, and any
control measures in place:
4. Did you review storm water monitoring data as part of this
NA, no monitoring
Yes
No
performed
inspection to identify potential pollutant hotspots?
If YES, summarize the findings of that review and describe any additional inspection activities resulting from this review:
5. Describe any evidence of pollutants entering the drainage system or discharging to surface waters, and the condition of and
around outfalls, including flow dissipation measure to prevent scouring:
6. Have you taken or do you plan to take corrective actions, as specified in Part 8 of the permit,
since your last annual report submission (or since you received authorization to discharge
Yes
No
under this permit if this is your first annual report), including any corrective actions identified
as a result of this annual comprehensive site inspection?
If YES, how many conditions requiring review for corrective action as specified in Parts 8.1 and 8.2 of the MSGP
were addressed by these corrective actions?
Note: Complete the attached Corrective Action Form (Section IV) for each condition identified, including any conditions identified as a result of
this comprehensive storm water inspection.
Page 2 of 6
MSGP Annual Report (Jan 2015)
For Agency Use
Permit Tracking #: ___________________
Section III. Industrial Activity Area Specific Findings
Complete one block for each industrial activity area where pollutants may be exposed to storm water. Copy this page for additional industrial activity areas.
In reviewing each area, you should consider:
Industrial materials, residue, or trash that may have or could come into contact with storm water;
Leaks or spills from industrial equipment, drums, tanks, and other containers;
Offsite tracking of industrial or waste materials from areas of no exposure to exposed areas; and
Tracking or blowing of raw, final, or waste material from areas of no exposure to exposed areas.
Industrial Activity Area:
1. Brief Description:
2. Are any control measures in need of maintenance or repair?
Yes
No
3. Have any control measures failed and require replacement?
Yes
No
4. Are any additional/revised control measures necessary in this area?
Yes
No
If YES, to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on
the attached Corrective Action Form.)
Industrial Activity Area:
1. Brief Description:
2. Are any control measures in need of maintenance or repair?
Yes
No
3. Have any control measures failed and require replacement?
Yes
No
4. Are any additional/revised control measures necessary in this area?
Yes
No
If YES, to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on
the attached Corrective Action Form.)
Page 3 of 6
MSGP Annual Report (Jan 2015)
For Agency Use
Permit Tracking #: ___________________
Industrial Activity Area:
1. Brief Description:
2. Are any control measures in need of maintenance or repair?
Yes
No
3. Have any control measures failed and require replacement?
Yes
No
4. Are any additional/revised control measures necessary in this area?
Yes
No
If YES, to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on
the attached Corrective Action Form.)
Industrial Activity Area:
1. Brief Description:
2. Are any control measures in need of maintenance or repair?
Yes
No
3. Have any control measures failed and require replacement?
Yes
No
4. Are any additional/revised control measures necessary in this area?
Yes
No
If YES, to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on
the attached Corrective Action Form.)
Page 4 of 6
MSGP Annual Report (Jan 2015)
For Agency Use
Permit Tracking #: ___________________
Section IV. Corrective Actions
Complete this page for each specific condition requiring a corrective action or a review determining that no corrective action is needed. Copy
this page for additional corrective actions or reviews.
Include both corrective actions that have been initiated or completed since the last annual report, and future corrective actions needed to
address problems identified in the comprehensive storm water inspection. Include an update on any outstanding corrective actions that had not
been completed at the time of your previous annual report.
of
for this reporting period.
1. Corrective Action #
2. Is this corrective action:
An update on a corrective action from a previous annual report; or
A new corrective action?
3. Identify the condition(s) triggering the need for this review:
Unauthorized release of discharge
Numeric effluent limitation exceedance
Control measures inadequate to meet applicable water quality standards
Control measures inadequate to meet non-numeric effluent limitations
Control measures not properly operated or maintained
Change in facility operations necessitated change in control measures
Average benchmark value exceedance
Other (describe):
4. Briefly describe the nature of the problem identified:
5. Date problem identified:
6. How problem was identified:
Comprehensive site inspection
Quarterly visual assessment
Routine facility inspection
Notification by EPA or DEC
Other (describe):
7. Description of corrective action(s) taken or to be taken to eliminate or further investigate the problem (e.g., describe
modifications or repairs to control measures, analysis to be conducted, etc.) or if no modification is needed, basis for that
determination.
Yes
No
8. Did/will this corrective action require modification of your SWPPP?
Page 5 of 6
MSGP Annual Report (Jan 2015)

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