Form 650-040-03 "Stormwater Pollution Prevention Plan Construction Inspection Report" - Florida

What Is Form 650-040-03?

This is a legal form that was released by the Florida Department of Transportation - a government authority operating within Florida. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Florida Department of Transportation;
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  • Fill out the form in our online filing application.

Download a fillable version of Form 650-040-03 by clicking the link below or browse more documents and templates provided by the Florida Department of Transportation.

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Download Form 650-040-03 "Stormwater Pollution Prevention Plan Construction Inspection Report" - Florida

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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
I certify under penalty of law that this document and all attachments were
CONTROL MEASURE CODES
CONDITION CODES
1. Temporary Grassing
19. Storm Inlet Sediment Trap
prepared under my direction or supervision in accordance with a system
2. Permanent Plant, Sod, or Seed
20. Stone Outlet Structure
designed to assure that qualified personnel properly gathered and
U
Upgrade Needed
3. Temporary Mulching
21. Curbs and Gutters
evaluated the information submitted. Based on my inquiry of the person
R
Replacement Needed
4. Artificial Covering
22. Storm Sewers
or persons who manage the system, or those persons directly
M Maintenance Needed
5. Buffer Zone
23. Velocity Control Devices
responsible for gathering the information, the information submitted is, to
C
Cleaning Needed
6. Silt Fence
24. Turbidity Barrier
the best of my knowledge and belief, true, accurate, and complete. I am
I
Increase Measures
7. Synthetic Bales
25. Haul Roads Dampened for Dust Control
aware that there are significant penalties for submitting false information,
8. Sand Bagging
26. Cleanup of Possible Contamination
S
Stable (no action)
9. Berms
27. Excess Dirt Removed from Rdwy Daily
including the possibility of fine and imprisonment for knowing violations.
10. Diversion, Interceptor, or Perimeter Ditches
28. Geotextile
Other:
11. Flumes
29. Filter Fabric
All maintenance operations needed to assure proper operation of all
12. Pipe Slope Drain
30. Rock Bags
controls, BMPs, practices, or measures identified in the Stormwater
13. Ditch Liner
31. Paved Road
Pollution Prevention Plan shall be done in a timely manner, but in no
Other:
14. Rock Bed at Construction Exit
32. Swale
case later than 7 calendar days following the inspection. The signature
15. Timber Mat or Construction Exit
33. Retention Pond
below also shall certify that this facility is in compliance with the
16. Rip Rap
34. Detention Pond
17. Sediment Trap
35. Tree Protection
Stormwater Prevention Plan and the State of Florida Generic Permit for
18. Sediment Basin
36.
Stormwater Discharge from Large and Small Construction Activities if
37.
there are not any incidents of non-compliance identified above.
____________________________________________________
Inspector Name:
Signature (Responsible Authority)
Signature:
Date Certified:
(Can be signed Digitally or Stylus)
Date Signed
Certification #:
(or other qualifications as described in Part II #12 of the permit)
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
I certify under penalty of law that this document and all attachments were
CONTROL MEASURE CODES
CONDITION CODES
1. Temporary Grassing
19. Storm Inlet Sediment Trap
prepared under my direction or supervision in accordance with a system
2. Permanent Plant, Sod, or Seed
20. Stone Outlet Structure
designed to assure that qualified personnel properly gathered and
U
Upgrade Needed
3. Temporary Mulching
21. Curbs and Gutters
evaluated the information submitted. Based on my inquiry of the person
R
Replacement Needed
4. Artificial Covering
22. Storm Sewers
or persons who manage the system, or those persons directly
M Maintenance Needed
5. Buffer Zone
23. Velocity Control Devices
responsible for gathering the information, the information submitted is, to
C
Cleaning Needed
6. Silt Fence
24. Turbidity Barrier
the best of my knowledge and belief, true, accurate, and complete. I am
I
Increase Measures
7. Synthetic Bales
25. Haul Roads Dampened for Dust Control
aware that there are significant penalties for submitting false information,
8. Sand Bagging
26. Cleanup of Possible Contamination
S
Stable (no action)
9. Berms
27. Excess Dirt Removed from Rdwy Daily
including the possibility of fine and imprisonment for knowing violations.
10. Diversion, Interceptor, or Perimeter Ditches
28. Geotextile
Other:
11. Flumes
29. Filter Fabric
All maintenance operations needed to assure proper operation of all
12. Pipe Slope Drain
30. Rock Bags
controls, BMPs, practices, or measures identified in the Stormwater
13. Ditch Liner
31. Paved Road
Pollution Prevention Plan shall be done in a timely manner, but in no
Other:
14. Rock Bed at Construction Exit
32. Swale
case later than 7 calendar days following the inspection. The signature
15. Timber Mat or Construction Exit
33. Retention Pond
below also shall certify that this facility is in compliance with the
16. Rip Rap
34. Detention Pond
17. Sediment Trap
35. Tree Protection
Stormwater Prevention Plan and the State of Florida Generic Permit for
18. Sediment Basin
36.
Stormwater Discharge from Large and Small Construction Activities if
37.
there are not any incidents of non-compliance identified above.
____________________________________________________
Inspector Name:
Signature (Responsible Authority)
Signature:
Date Certified:
(Can be signed Digitally or Stylus)
Date Signed
Certification #:
(or other qualifications as described in Part II #12 of the permit)
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
650-040-03
Financial Project #
CONSTRUCTION
STORMWATER POLLUTION PREVENTION PLAN
03/19
CONSTRUCTION INSPECTION REPORT
CONTRACT #
(Weekly and within 24 hrs. of the end
COMPANY NAME
S.R. #
of a storm that is 0.50 in. or greater)
INSPECTION DATE
Date of Rainfall
Page
Amount Recorded
FDEP Permit #
A c t i v e W o r k
L o c a t i o n o f
A p p r o x i m a t e S t a t i o n s
L t . O r R t .
Z o n e = A
D a t e L a s t
D a t e o f
C o n t r o l
C u r r e n t
C o r r e c t i v e A c t i o n o r R e m a r k s
C o n t r o l
O f
D i s t u r b e d
S t a b i l i z a t i o n
M e a s u r e s
C o n d i t i o n
M e a s u r e
F r o m
T o
C e n t e r l i n e
I n a c t i v e
( U s e
( U s e
W o r k Z o n e = I
C o d e s
C o d e s
B e l o w )
B e l o w )
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