Form CEM-2075T "Project Stormwater Annual Report - Lake Tahoe Hydrologic Unit" - California

What Is Form CEM-2075T?

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 February 1, 2019;
  • The latest edition provided by the California Department of Transportation;
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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 1 of 7
CEM-2075T (REV 02/2019)
GENERAL INFORMATION
A. SITE OWNER INFORMATION
OWNER NAME
OWNER CONTACT
OWNER ADDRESS
EMAIL
PHONE
703 B Street
CITY
STATE
ZIP CODE
Marysville
CA
95901
B. SITE INFORMATION
SITE BUSINESS NAME
SITE CONTACT
Caltrans District 03
SITE WDID NUMBER
EMAIL
PHONE
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
CA
FORM 1
C. STORMWATER POLLUTION PREVENTION PLAN (SWPPP)
C.1.
Has a SWPPP been prepared by a Qualified SWPPP Developer (QSD) for the construction project?
YES
NO
If NO, explain:
C.2.
Does the SWPPP include a Construction Site Monitoring Program (CSMP) section/element?
YES
NO
If NO, explain:
C.3.
Are these documents kept on-site?
YES
NO
If NO, explain:
D. GOOD SITE MANAGEMENT (i.e. HOUSEKEEPING)
D.1.
Were good site management (i.e. housekeeping) measures for construction materials implemented
on-site in accordance with Lake Tahoe Construction General Permit (LTCGP) and SWPPP?
YES
NO
If NO, explain:
D.1.a.
Was an inventory of the products used and/or expected to be used conducted?
YES
NO
If NO, explain:
D.2.
Were required good site management (i.e. housekeeping) measures for waste management
implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.2.a. Is there a spill response and implementation element for the SWPPP?
YES
NO
If NO, explain:
D.3.
Were required good site management (i.e. housekeeping) measures for vehicle storage and
maintenance implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.4.
Were required good site management (i.e. housekeeping) measures for landscape materials
implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.5.
Was a list of potential pollutant sources developed?
YES
NO
If NO, explain:
D.6.
Were required good site management (i.e. housekeeping) measures to control air deposition of site
materials and from site operations implemented on-site?
YES
NO
If NO, explain:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 1 of 7
CEM-2075T (REV 02/2019)
GENERAL INFORMATION
A. SITE OWNER INFORMATION
OWNER NAME
OWNER CONTACT
OWNER ADDRESS
EMAIL
PHONE
703 B Street
CITY
STATE
ZIP CODE
Marysville
CA
95901
B. SITE INFORMATION
SITE BUSINESS NAME
SITE CONTACT
Caltrans District 03
SITE WDID NUMBER
EMAIL
PHONE
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
CA
FORM 1
C. STORMWATER POLLUTION PREVENTION PLAN (SWPPP)
C.1.
Has a SWPPP been prepared by a Qualified SWPPP Developer (QSD) for the construction project?
YES
NO
If NO, explain:
C.2.
Does the SWPPP include a Construction Site Monitoring Program (CSMP) section/element?
YES
NO
If NO, explain:
C.3.
Are these documents kept on-site?
YES
NO
If NO, explain:
D. GOOD SITE MANAGEMENT (i.e. HOUSEKEEPING)
D.1.
Were good site management (i.e. housekeeping) measures for construction materials implemented
on-site in accordance with Lake Tahoe Construction General Permit (LTCGP) and SWPPP?
YES
NO
If NO, explain:
D.1.a.
Was an inventory of the products used and/or expected to be used conducted?
YES
NO
If NO, explain:
D.2.
Were required good site management (i.e. housekeeping) measures for waste management
implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.2.a. Is there a spill response and implementation element for the SWPPP?
YES
NO
If NO, explain:
D.3.
Were required good site management (i.e. housekeeping) measures for vehicle storage and
maintenance implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.4.
Were required good site management (i.e. housekeeping) measures for landscape materials
implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
D.5.
Was a list of potential pollutant sources developed?
YES
NO
If NO, explain:
D.6.
Were required good site management (i.e. housekeeping) measures to control air deposition of site
materials and from site operations implemented on-site?
YES
NO
If NO, explain:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 2 of 7
CEM-2075T (REV 02/2019)
E.
NON-STORM WATER MANAGEMENT
E.1.
Were measures to control all non-storm water discharges during construction implemented?
YES
NO
If NO, explain:
E.2.
Were vehicles washed in such a manner as to prevent non-storm water discharges to surface waters
or to MS4 drainage systems?
YES
NO
NA
If NO, explain:
E.3.
Were streets cleaned in such a manner as to prevent unauthorized non-storm water discharges from
reaching surface waters or MS4 drainage systems?
YES
NO
If NO, explain:
F.
EROSION CONTROLS
F.1.
Were required erosion controls implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
G. SEDIMENT CONTROLS
G.1.
Were required sediment controls implemented on-site in accordance with LTCGP and SWPPP?
YES
NO
If NO, explain:
G.2.
Were immediate access roads inspected on a daily basis?
YES
NO
If NO, explain:
G.3.
Was an Active Treatment System implemented on-site?
YES
NO
H. RUN-ON AND RUN-OFF CONTROLS
H.1.
Was all site run-on and run-off effectively managed?
YES
NO
If NO, explain:
H.2.
Did discharger monitor and report run-on from surrounding areas if there was reason to believe run-on
may have contributed to a Numeric Action Level (NAL) exceedance for pH or a Numeric Effluent
Limitations (NEL) exceedance?
YES
NO
NA
If NO, explain:
I.
RAIN EVENT ACTION PLAN (REAP)
I.1.
Were REAPs developed 48 hours prior to all likely precipitation events (30% or greater probability of
producing precipitation)?
YES
NO
If NO, explain:
I.2.
Did the REAPs developed meet the minimum criteria listed in the LTCGP?
YES
NO
If NO, explain:
I.3.
Was a REAP developed for each qualifying event in accordance with the permit requirements
(i.e. Grading and Land Development, Streets and Utilities, Vertical Construction, Final Landscaping
and Site Stabilization)?
YES
NO
If NO, explain:
J.
INSPECTION, MAINTENANCE, AND REPAIR
J.1.
Were all site inspections, maintenance, and repairs performed or supervised by a Qualified SWPPP
Practitioner (QSP)?
YES
NO
If NO, explain:
J.2.
Were site inspections conducted daily, weekly, and at least once each 24-hour period during extended
storm events?
YES
NO
If NO, explain:
J.3.
Were post rain event inspections conducted?
YES
NO
If NO, explain:
J.4.
Do your inspection forms/checklists meet the minimum criteria listed in the LTCGP?
YES
NO
If NO, explain:
J.5.
During any site inspection was Best Management Practice (BMP) maintenance or repairs required?
YES
NO
If yes, provide summary in Form 2.
J.6.
If BMP maintenance/repair or design change was needed, was it completed within 72 hours?
YES
NO
NA
If NO, explain:
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 3 of 7
CEM-2075T (REV 02/2019)
K. *SECTION K - NOT APPLICABLE FOR LAKE TAHOE ANNUAL REPORT
L.
WATER QUALITY SAMPLING AND ANALYSIS
L.1.
How many storm events producing a discharge off the project boundaries occurred this past reporting year?
L.2.
How many storm events were sampled?
Explain un-sampled events:
L.3.
For the sample event, did you collect three samples, at minimum? (Representative of the flow and
characteristics)
YES
NO
NA
If NO, explain:
L.4.
Were grab samples analyzed for turbidity? (Analytical data must be entered in the RAW DATA tab in
SMARTS)
YES
NO
NA
If NO, explain:
L.5.
Were Active Treatment System (ATS) effluent samples taken? (Applies to projects that deployed ATS)
YES
NO
NA
If NO, explain:
L.6.
Was receiving water monitoring conducted? (Analytical data must be entered in the RAW DATA tab in
SMARTS)
YES
NO
NA
If NO, explain:
M. NON-STORMWATER DISCHARGE MONITORING
M.1.
Were all drainage areas monitored for authorized/unauthorized non-storm water discharge?
YES
NO
NA
If NO, explain:
M.2.
Did visual observation indicate any authorized/unauthorized non-stormwater discharge? (Complete Form 2)
YES
NO
NA
If NO, explain:
M.3.
Were effluent samples taken of the authorized/unauthorized non-stormwater discharge? (Analytical data
must be entered into the RAW DATA tab in SMARTS)
YES
NO
NA
If NO, explain:
M.4.
Were the effluent samples sent to a laboratory certified for such analyses by the California Department
of Public Health?
YES
NO
NA
If NO, explain:
M.5.
Were unauthorized non-stormwater discharges eliminated?
YES
NO
NA
If NO, explain:
N. NON-VISIBLE POLLUTANT MONITORING
N.1.
Were any breaches, malfunctions, leakages, or spills observed during a visual inspection?
YES
NO
NA
N.2.
How many potential discharges of non-visible pollutants were identified?
YES
NO
NA
N.3.
For each discharge event (of non-visible pollutants), were samples collected in compliance with the
LTCGP? (Analytical data must be entered into the RAW DATA tab in SMARTS)
YES
NO
NA
If NO, explain:
N.4.
For each discharge event, was a comparison sample collected (uncontaminated sample that did not come
into contact with the pollutant)? (Analytical data must be entered into the RAW DATA tab in SMARTS)
YES
NO
NA
If NO, explain:
O. *SECTION O - NOT APPLICABLE FOR LAKE TAHOE ANNUAL REPORT
P.
RECORDS
P.1.
Are all records of all stormwater monitoring information retained on-site?
YES
NO
If NO, explain:
Q. *SECTION Q - NOT APPLICABLE FOR LAKE TAHOE ANNUAL REPORT
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 4 of 7
CEM-2075T (REV 02/2019)
R. NEL EXCEEDANCES
R.1.
Were any Numeric Effluent Limitations (NELs) exceeded?
YES
NO
NA
If NO or N/A, skip to next section.
R.2.
Were any NEL exceedances due to a storm event equal to or larger than the Compliance Storm Event
described in CGP? (On-site rain gauge and governmental rain gauge verification required)
EQUAL
LARGER
If YES, explain:
R.3.
Were corrective actions taken to address the NEL exceedances?
EQUAL
LARGER
If YES, please provide information about the corrective actions taken on Form 2.
If NO, explain:
R.4.
Were NEL Violation Reports submitted to the State Water Board within 24 hours after the NEL
exceedance were identified?
YES
NO
If NO, explain:
R.5.
Were analytical/sampling results from any/all NEL exceedances submitted electronically to the State
Water Board, no later than 5 days after the conclusion of the storm event?
YES
NO
If NO, explain:
S.
BIOASSESSMENT
S.1.
Is the project over 30 acres?
YES
NO
If NO, skip to the next section
S.2.
Does the project have a direct connection to a freshwater wade-able (generally less than 0.5-1.0
meters deep that can be sampled by field crews wearing chest waders) receiving water?
YES
NO
If NO, skip to the next section
S.3.
Have you already submitted bioassessment information in a previous annual report?
YES
NO
Note: If you have not already submitted your bioassessment information, please provide the information
(electronically) from the group that did the assessment or a summary of the information. Please
include what party conducted the assessment for the site.
If NO, skip to next section
S.4.
Was the benthic macroinvertebrate bioassessment commenced in accordance to the instructions in
Appendix C-1 of the permit?
YES
NO
If NO, explain:
S.5.
Was your site exempted by the Regional Water Board?
YES
NO
If YES, provide documentation
If NO, explain:
S.6.
Were you required to pay into a comparable monitoring program (i.e. SWAMP)?
YES
NO
If YES, go to next section
If NO, explain:
T.
TRAINING
T.1.
Was a Qualified SWPPP Practitioner (QSP) in reasonable charge of SWPPP implementation?
YES
NO
If YES, provide name:
and certificate number:
If NO, explain:
T.2.
Were all individuals conducting BMP installation, inspection, maintenance, and repairs trained
appropriately?
YES
NO
If NO, explain:
T.3.
Are complete training records kept on-site and available upon request?
YES
NO
If NO, explain:
U. AUTHORIZED NON-STORMWATER DISCHARGE (NSWD) DISCHARGED
U.1.
Were any authorized NSWDs discharged/observed from May 1 to October 15?
YES
NO
If YES, complete Form 2.
V.
UNAUTHORIZED NON-STORMWATER DISCHARGE (NSWD) DISCHARGED
V.1.
Were any unauthorized NSWDs discharged/observed from May 1 to October 15?
YES
NO
If YES, complete Form 2.
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.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PROJECT STORMWATER ANNUAL REPORT - LAKE TAHOE HYDROLOGIC UNIT
Page 5 of 7
CEM-2075T (REV 02/2019)
FORM 2
DESCRIBE NSWD CHARACTERISTICS. Indicate whether
DATE/TIME
AUTHORIZED OR
SOURCE AND
NSWD is clear, cloudy, or discolored, causing staining,
DESCRIBE ANY REVISED OR NEW BMPs
contains floating objects or oil sheen, has odors, etc.
OF
UNAUTHORIZED
LOCATION OF
NAME OF NSWD
AND PROVIDE THEIR IMPLEMENTATION
OBSERVATION
(CHECK ONE)
NSWD
DATE
At the NSWD Drainage Area
At the NSWD Source
and Discharge Location
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
Authorized
Unauthorized
AM
PM
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.