DEQ Form 606-005 "Annual Comprehensive Site Comliance Evaluation Report (Acscer) for Stormwater Discharges Associated With Industrial Activity Under the Opdes Multi-Sector General Permit Okr05" - Oklahoma

What Is DEQ Form 606-005?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 5, 2017;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • 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 DEQ Form 606-005 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 606-005 "Annual Comprehensive Site Comliance Evaluation Report (Acscer) for Stormwater Discharges Associated With Industrial Activity Under the Opdes Multi-Sector General Permit Okr05" - Oklahoma

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Oklahoma Department of Environmental Quality
DEQ Form
Annual Comprehensive Site Compliance Evaluation Report (ACSCER)
606-005
for Stormwater Discharges Associated with Industrial Activity
July 5, 2017
under the OPDES Multi-Sector General Permit OKR05
Submission of this ACSCER form is required for all authorized industrial facilities.
All requested information must be provided on this form. See instructions on Page 5 of this form.
DEQ Authorization Number: OKR05
________________________________
Part A: Operator Information and Certification
Section I. Operator Information
Operator Name:
_____________________________________________________________________________________
Mailing Address:
City:
_______________________________________________________
________________________
County:
State:
Zip Code:
__________________________
________
__________________
Operator’s Point of Contact :
Title:
___________________________________________
___________________________
Phone:
Email:
___________________________
_____________________________________________
Section II. Facility Information
Facility Name:
Phone:
____________________________________________________
___________________________
Address:
__________________________________________________________________________________________
OK
City:
County:
State:
Zip Code:
_____________________
__________________________
______
_____________
Latitude:
Longitude:
_______________________
___________________________
Facility’s Point of Contact :
Title:
____________________________________________
____________________________
Phone:
E-mail:
_________________________
_____________________________________________
Section III. Certification
I certify under penalty of law that I have read and understand the requirements for filing this Annual Comprehensive Site
Compliance Evaluation Report, which is to be filed by March 1 of each year beginning in 2018.
This report is also to be retained as part of the Stormwater Pollution Prevention Plan (SWP3) for at least 3 years from the date
permit coverage expires or is terminated and will be made available to any State or Federal Inspector visiting this facility. All
records of actions taken in accordance with 4.10 of this Permit as part of the SWP3 will be retained for at least 3 years from the
date permit coverage expires or is terminated. 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
gathered and evaluated the information submitted. Based upon my inquiry of the person or persons who manage the system, or
those persons directly involved in gathering the information, the information submitted is to the best of my knowledge and belief
true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name:
Title:
_______________________________________________
_________________________________
Signature:
Date:
______________________________________________
___________________________
Oklahoma Department of Environmental Quality
DEQ Form
Annual Comprehensive Site Compliance Evaluation Report (ACSCER)
606-005
for Stormwater Discharges Associated with Industrial Activity
July 5, 2017
under the OPDES Multi-Sector General Permit OKR05
Submission of this ACSCER form is required for all authorized industrial facilities.
All requested information must be provided on this form. See instructions on Page 5 of this form.
DEQ Authorization Number: OKR05
________________________________
Part A: Operator Information and Certification
Section I. Operator Information
Operator Name:
_____________________________________________________________________________________
Mailing Address:
City:
_______________________________________________________
________________________
County:
State:
Zip Code:
__________________________
________
__________________
Operator’s Point of Contact :
Title:
___________________________________________
___________________________
Phone:
Email:
___________________________
_____________________________________________
Section II. Facility Information
Facility Name:
Phone:
____________________________________________________
___________________________
Address:
__________________________________________________________________________________________
OK
City:
County:
State:
Zip Code:
_____________________
__________________________
______
_____________
Latitude:
Longitude:
_______________________
___________________________
Facility’s Point of Contact :
Title:
____________________________________________
____________________________
Phone:
E-mail:
_________________________
_____________________________________________
Section III. Certification
I certify under penalty of law that I have read and understand the requirements for filing this Annual Comprehensive Site
Compliance Evaluation Report, which is to be filed by March 1 of each year beginning in 2018.
This report is also to be retained as part of the Stormwater Pollution Prevention Plan (SWP3) for at least 3 years from the date
permit coverage expires or is terminated and will be made available to any State or Federal Inspector visiting this facility. All
records of actions taken in accordance with 4.10 of this Permit as part of the SWP3 will be retained for at least 3 years from the
date permit coverage expires or is terminated. 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
gathered and evaluated the information submitted. Based upon my inquiry of the person or persons who manage the system, or
those persons directly involved in gathering the information, the information submitted is to the best of my knowledge and belief
true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name:
Title:
_______________________________________________
_________________________________
Signature:
Date:
______________________________________________
___________________________
Part B: Annual Comprehensive Site Compliance Evaluation
Reporting Period:
1.
Number of routine facility inspections you performed during the reporting period:
Dates of the Inspection
2.
performed:
Did any of your routine facility inspections find that one or more of your BMPs was not effective in controlling
3.
the pollutant source for which it was designed?
Yes
No
All BMPs were effective
Were all BMPs you indicated you would be using in your SWP3 (Part 4.2.4), including good housekeeping
4.
practices, actually being implemented at the time of the Annual Comprehensive Site Compliance Evaluation?
Yes
No
If you found one or more ineffective BMPs, have they all been replaced with an alternative or modified BMP?
5.
Yes
No
All BMPs were being effective
6.
Were there additional BMPs needed to address any conditions requiring corrective action?
Yes
No
If one or more BMPs were not being implemented, were corrective actions taken after the first inspection to
7.
eliminate the problem?
Yes
No
All BMPs were being implemented
8.
Was/were the same failure(s) to implement a BMP deficiency(ies) noted in more than one inspection?
Yes
No
No deficiencies noted in any inspection
Document any deficiencies identified and any corrective actions implemented (see Part 6 of OKR05) to remove
9.
the original violation below. Use additional sheets if necessary.
Date
Deficiencies
Corrected
Date of Correction
Yes
No
Yes
No
Yes
No
Yes
No
10.
What must you do to correct the deficiencies that remain uncorrected?
Did any conditions require SWP3 review and revision to eliminate design, selection, installation, and/or
11.
implementation problem during the past year? If yes, describe the conditions in brief:
No
Yes
At any time during the reporting period, did you discover any previously unidentified unauthorized non-
12.
stormwater discharges from your facility or previously unidentified pollutants in the existing discharges?
Yes
No
Have all unauthorized non-stormwater discharges (including any discovered in previous years) been eliminated
13.
or permitted?
Yes
No
Permit applied for
No unauthorized discharges
14.
Have any significant spills or leaks occurred at your facility during the reporting period?
Yes
No
If any significant spills or leaks occurred, did they result in either a dry weather discharge or an actual discharge
15.
of the spilled or leaked material commingled with stormwater (as opposed to the spilled material being washed
away by stormwater?)
Yes
No
If any significant spills or leaks occurred, did they result in more than the minimum amounts of material being
discharged in stormwater? Base your answer on your knowledge of the material you spilled or that leaked. The
16.
minimum amounts could vary with the nature (toxicity, oxygen demand, pH, etc.) of the spilled or leaked
material from amounts left after normal sweeping type cleanup to the point at which even trace amounts left
after cleanup could cause an environmental problem.
Yes
No
No spills or leaks occurred
Have all known spills or leaks been cleaned up or otherwise prevented from contaminating stormwater that
17.
would be discharged under the authority of this permit?
Yes
No
No spills or leaks occurred
How many times did you visually monitor all of your stormwater discharges at all the outfalls during the
18.
reporting year (
?
count only those done in accordance with the procedures at Part 5.1 - Quarterly Visual Monitoring)
Would the results of your visual monitoring indicate that there are pollutants in your stormwater discharges that
19.
are not adequately controlled by your current BMPs?
Yes
No
20.
If the results of your visual monitoring indicated a potential problem, was it due to one or more of the following?
New pollutant source (including exposure of previously unexposed material)
Failure to implement or maintain an existing BMP
Less than expected performance from a BMP
No BMP was selected to deal with that problem
N/A (No problems identified)
21.
If your visual monitoring indicated a potential problem, what have you done to resolve the problem?
Eliminated exposure or pollutant source
Modified existing BMPs
Added a new BMP
Plan to address problem by end of current reporting year
Nothing planned
N/A (No problems identified)
Did any monitoring results exceed a numeric effluent limitation contained in Part 7.2.2 and Part 11 during the
22.
past discharge monitoring period?
Yes
No
If your answer to the previous question was Yes, list the dates, name of the pollutants and the test results that
23.
exceeded numeric effluent limitations. Use additional sheets if necessary.
Date
Pollutants
Test Results
Date
Pollutants
Test Results
24.
Were there any incidents of noncompliance in the past year or any non-compliance that is currently ongoing?
Yes
No
Compliant with the Permit
25.
Were there any required revisions to the SWP3 resulting from the inspection and/or monitoring?
Yes
No
If your answer to the previous question was Yes, list the dates, reason for revision and brief description of the
26.
revision. Use additional sheets if necessary.
Date
Reason for Revision
Description of Revision
Instructions for Completing
the Annual Comprehensive Site Compliance Evaluation Report (ACSCER)
Form 606-005 for Stormwater Discharges Associated with Industrial Activity
When to File an ACSCER Form
Part B: Annual Comprehensive Site Compliance Evaluation
Permittees who are presently covered under OPDES MSGP
Report
OKR05 for stormwater discharges associated with industrial
activity must submit an ACSCER form to DEQ by March 1 of
1. A summary of your past year’s routine facility inspection
documentation such as control measures’ maintenance,
each year beginning in 2018. If your authorization becomes
effective less than one month from the end of the yearly
repair and/or replacement, any additional control measures
monitoring period, your first monitoring period starts with the
needed to comply with the permits;
next annual monitoring period.
2. The location(s) of discharges of pollutants from the site,
evidence of pollutants discharging to receiving waters at all
Completing the Form
facility outfall(s), and the condition of and around the
To complete this form, type or print in the appropriate areas
outfall(s);
only.
3. A summary of your past year’s corrective action
documentation;
Permit Information
4. A summary of your past year’s quarterly visual monitoring
Enter the existing DEQ Authorization assigned to the facility
documentation;
identified in Section I for stormwater discharges from
industrial activity.
5.
A summary of your past year’s effluent limitation violations
if applicable; and
Part A: Operator Information and Certification
6.
Describe any incidents of noncompliance in the past year or
Section I. Operator Information
currently ongoing, or if none, provide a statement that you
Provide the legal name of the person, firm, public
are in compliance with the Permit.
organization or any other commercial entity that owns or
Note: Please see Part 8.3 of OKR05 for detailed scope of Annual
operates the facility described in this application. The name of
Comprehensive Site Compliance Evaluation.
the operator may or may not be the same name as the
facility. An operator is the legal entity that controls the
Completed ACSCER form must be submitted to DEQ by
facility's operation, rather than the plant or site manager.
March 1 of each year beginning in 2018.
Provide complete mailing address including city, county, state,
and ZIP code. Include operator’s point of contact name, title,
If you need any assistance or have any question, contact the
telephone number and a valid email address.
Stormwater Unit of Environmental Complaints and Local Services
(ECLS) of DEQ at (405) 702-6100 or email to:
Section II. Facility Information
ecls-stormwaterpermitting@deq.ok.gov
Enter the facility’s official or legal name and complete physical
address including city, county, state, and ZIP code. Include
Where to file an ACSCER Form
facility’s point of contact name, telephone number and email
Completed ACSCER form must be submitted to the following
address. Indicate the latitude and longitude of the facility to
address:
the nearest 15 seconds. . Include facility’s point of contact
name, title, telephone number and a valid email address.
Stormwater Unit of ECLS
Oklahoma DEQ
Section III. Certification
P.O. Box 1677
The ACSCER form must be signed by a responsible party - for
Oklahoma City, OK 73101-1677
corporation: by a responsible corporate official, such as:
president, vice president, secretary, and treasurer either for a
or fax it to: (405)702-6226
corporation or company; for a partnership or sole
or email it to:
ecls-stormwaterpermitting@deq.ok.gov
proprietorship: by a general partner or the proprietor,
respectively. (Note: for limited liability company (LLC): by one
Commencing December 21, 2020, ACSCERs must be electronically
of its owners, called managing members/partners of the
submitted to DEQ. Instructions on how to access and use the
company); for a municipality, state, Federal, or other public
appropriate electronic reporting tool will be made available on
facility: by either a principal executive or ranking elected
DEQ’s website prior to the December 21, 2020 compliance
official.
deadline.
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