Form AR-SWI "Annual Report Form - Multi-Sector General Permit for Storm Water Discharges Associated With Industrial Activity (Msgp) Mtr000000" - Montana

What Is Form AR-SWI?

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

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Montana 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 Form AR-SWI by clicking the link below or browse more documents and templates provided by the Montana Department of Environmental Quality.

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Download Form AR-SWI "Annual Report Form - Multi-Sector General Permit for Storm Water Discharges Associated With Industrial Activity (Msgp) Mtr000000" - Montana

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Page background image
Agency Use
Permit No.:
Date Rec’d
Amount Rec’d
Check No.
Rec’d By
Annual Report Form
FORM
Multi-Sector General Permit for Storm Water Discharges
AR-SWI
Associated with Industrial Activity (MSGP)
MTR000000
An Annual Report Form must be completed and submitted to the Department for each calendar year of active coverage
under this permit. This Annual Report must be completed using this standard form. The Annual Report for a given
calendar year must be submitted by February 1 of the year following that respective calendar year. The permittee is waived
from Annual Report requirements for a given calendar year if authorization to discharge was obtained less than three
months before the end of that respective calendar year. The Annual Report must be certified and signed in accordance with
Part 4.18 of the MSGP.
Section A - Facility or Operation Information
Permit Authorization Number: MTR00 __ __ __ __
Facility or Operation Name ___________________________________________________________________________
Physical Location, Mailing address, or directions to location
___________________________________________________________________________________________________
Nearest City or Town __________________ Zip Code_______________________County________________________
Latitude ______________________________ Longitude ____________________________________________
Township/Range /Section (optional)____________________________________________________________________
Facility or Operation Contact Person/Position
Name and Title, or Position Title_______________________________________________________________________
Company Name (if different than the facility or operation _________________________________________________
Mailing Address ____________________________________________________________________________________
City, State, and Zip Code _____________________________________________________________________________
Phone Number (
)
E-mail ___________________________________________________
SWPPP Administrator
Same as facility contact
Name and Title
Company Name (if different than the applicant)
Mailing Address
City, State, and Zip Code __________________________________________________________________________
Phone Number (
)
E-mail _______________________________________________
January 2018
AR-SWI
Page 1 of 4
Agency Use
Permit No.:
Date Rec’d
Amount Rec’d
Check No.
Rec’d By
Annual Report Form
FORM
Multi-Sector General Permit for Storm Water Discharges
AR-SWI
Associated with Industrial Activity (MSGP)
MTR000000
An Annual Report Form must be completed and submitted to the Department for each calendar year of active coverage
under this permit. This Annual Report must be completed using this standard form. The Annual Report for a given
calendar year must be submitted by February 1 of the year following that respective calendar year. The permittee is waived
from Annual Report requirements for a given calendar year if authorization to discharge was obtained less than three
months before the end of that respective calendar year. The Annual Report must be certified and signed in accordance with
Part 4.18 of the MSGP.
Section A - Facility or Operation Information
Permit Authorization Number: MTR00 __ __ __ __
Facility or Operation Name ___________________________________________________________________________
Physical Location, Mailing address, or directions to location
___________________________________________________________________________________________________
Nearest City or Town __________________ Zip Code_______________________County________________________
Latitude ______________________________ Longitude ____________________________________________
Township/Range /Section (optional)____________________________________________________________________
Facility or Operation Contact Person/Position
Name and Title, or Position Title_______________________________________________________________________
Company Name (if different than the facility or operation _________________________________________________
Mailing Address ____________________________________________________________________________________
City, State, and Zip Code _____________________________________________________________________________
Phone Number (
)
E-mail ___________________________________________________
SWPPP Administrator
Same as facility contact
Name and Title
Company Name (if different than the applicant)
Mailing Address
City, State, and Zip Code __________________________________________________________________________
Phone Number (
)
E-mail _______________________________________________
January 2018
AR-SWI
Page 1 of 4
Section B – Summary of Findings
Provide a summary of the past year’s routine facility inspections documentation.
Provide a summary of the past year’s significant storm event inspection documentation.
January 2018
AR-SWI
Page 2 of 4
Provide a summary of the past year’s corrective actions performed - be sure to provide a tracking or follow-up
process for any currently ongoing and unresolved actions.
Provide a summary of any incidents of noncompliance observed – be sure to provide a tracking or follow-up process
for any currently ongoing and unresolved incidents. Enter “NA” if not applicable.
Provide a summary of the past year’s benchmark monitoring results (if applicable). Enter “NA” if not applicable.
January 2018
AR-SWI
Page 3 of 4
Provide a summary of the past year’s required revisions to the SWPPP. If the SWPPP is maintained on an internet
page, provide the web address URL: ____________________________________.
Section C - Certification
I certify that the facility or operation identified in Section A of this AR-SWI form:
Modifies and updates the SWPPP as required by Part 3.2;
Maintains a complete copy of the current SWPPP at the facility in an accessible format; and
Confirms that the current SWPPP or certain information from the current SWPPP must also be made available to
the public upon request.
Authorized Signatories: This form must be completed, signed, and certified as follows:
For a corporation, by a principal officer of at least the level of vice president;
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
For a municipality, state, federal, or other public facility, by either a principal executive officer or ranking
elected official.
All Applicants Must Complete the Following 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 persons who manage the system, or those persons directly responsible for gathering
the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am
aware that there are significant penalties for submitting false information; including the possibility of a fine and
imprisonment for knowing violations.
Name (Type or Print)
Title (Type or Print)
Phone Number
Signature
Date Signed
January 2018
AR-SWI
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