Spreadsheet: 0ec00c91-f223-4fd7-ad0e-4533153c6c40
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | UPDES STORM WATER INSPECTION EVALUATION FORM FOR  SWPPP COMPLIANCE | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Insert City  Logo Here | Unnamed: 13 | Unnamed: 14
BACKGROUND INFORMATION
Project Name: |  |  |  |  |  |  |  |  |  | UPDES Permit #:
Proj. Location:
Local Jurisdiction or County:
Permit Effective Date: |  |  |  |  |  |  | Permit Expiration Date:
Total Project Area: |  |  |  |  |  |  | Total Disturbed Area:
Project Type: (circle) |  | Subdivision |  |  | Commercial |  |  | Industrial |  | Linear (Road/Pipe/Power) |  | Land Disturbance
OPERATOR CONTACT INFORMATION
 |  | NAMES |  |  |  | PHONE NUMBERS |  |  | E-MAIL
Operator:
Onsite Facility Contact:
Important Contacts:
Important Contacts:
SWPPP PRE-SITE REVIEW INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  | YES | NO
1. Has a pre-construction review of the finalized SWPPP been conducted by UDOT?
2. Are Contractor and UDOT contact names and telephone numbers listed in the SWPPP?
3. Does the SWPPP include a site map showing storm drains, slopes/surface drainage patterns, SW discharge points, construction boundaries, limits of disturbance, surface waters (name of receiving water), structural controls, and does it define/explain non-structural controls?
4. Does the SWPPP have an estimate of the area to be disturbed, a sequence of construction activities, controls for discharges from (asphalt/concrete) batch plants if any, show wetland areas, and have a desription of the nature of the construction activity?
5. Does the SWPPP and site map show erosion and sediment controls placement & details (e.g. erosion blankets, mulch, slope drains, check dams, sediment basins, grass-lined channels, fiber rolls, sediment traps, silt fence, inlet protection, curb cut-back, dust control, etc?)
6. Does the SWPPP and site map show and describe good housekepping  controls (e.g. track out pad, street sweeping, material storage, construction waste containment and removal, sanitary waste, concrete washout pits, etc)
7. Are post-construction elements included in the SWPPP?  (i.e. grass swales, detention basins, vegetated filter strips, infiltration, depression storage, landscaping/xeriscaping, discontinuous concrete or hard surface SW conveyance, etc.)
8. Does the SWPPP address endangered species and historic preservation?
9. Is the SWPPP signed by the Contractor's responsible corporate officer and UDOT's RE with the certification statement?
10. Are the NOI and a copy of the Construction General Permit in the SWPPP?
NOTICE OF TERMINATION (NOT) INSPECTION
Project Name: |  |  |  |  |  |  | Date of Evaluation:
Proj. Location:
Inspected By: |  |  |  |  |  |  | Title\Organization:
 |  |  |  |  |  | YES | NO | COMMENTS:
1. Has the site been properly stabilized according to permit requirements?
2. Have all temporary BMPs been removed?
3. Have post-construction (permanent storm water system) elements been constructed and inspected in accordance with approved project drawings?
4. Is the site acceptably clean?
Municipal Inspector (print): |  |  |  |  |  | Signature:
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 on my inquiry of the person or 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.fine and imprisonment for knowing violations.
Inspector:
 | (Print Name) |  |  | (Title) |  |  |  |  | (Signature) |  |  | (Date)
Operator:
modified 8/12/10 | (Print Name) |  |  | (Title) |  |  |  |  | (Signature) |  |  | (Date)
(Attach additional sheets of narrative, pictures and checklists, as necessary)
 |  | ADDITIONAL COMMENTS AND CORRECTIVE ACTIONS FOR  SWPPP COMPLIANCE
Project Name: |  |  |  |  |  |  | Date of Evaluation: |  |  |  | Page |  | of
Proj. Location:
EPA Form 3560-3 SEV Codes and Descriptions
DOR11 |  | Discharge without a permit |  |  |  |  |  | BR19B |  | Failure to properly operate and maintain BMP's
DOR18 |  | Failure to apply for a Notice of Termination |  |  |  |  |  | BR19A |  | Failure to properly install/implement BMP's
BOR12 |  | Failure to conduct inspections |  |  |  |  |  | EOR16 |  | Failure to submit required report (non-DMR)
BOC17 |  | Failure to develop any or adequate [NAME]/SWMP |  |  |  |  |  | AOR22 |  | Narrative effluent violation
BOC18 |  | Failure to implement [NAME]/SWMP |  |  |  |  |  | DOR12 |  | Failure to submit required permit  information
BOR41 |  | Failure to maintain records |  |  |  |  |  | AOR12 |  | Numeric effluent violation
COR11 |  | Failure to monitor |  |  |  |  |  | BOR42 |  | Violation of a milestone in an order