Stormwater Industrial Routine Facility Inspection Report General Information Facility Name Insert Name NPDES Tracking No. Insert Tracking No. Date of Inspection Insert Date Start/End Time Insert Start/End Time Inspector’s Name(s) Insert Name Inspector’s Title(s) Insert Title Inspector’s Contact Information Insert Contact Info Inspector’s Qualifications Insert qualifications or add reference to the Weather Information Weather at time of this inspection? Clear Cloudy Rain Sleet Fog Snow High Winds Other: Temperature: Have any previously unidentified discharges of pollutants occurred since the last inspection? Yes No If yes, describe: Describe Are there any discharges occurring at the time of inspection? Yes No If yes, describe: Describe Control Measures Number the structural stormwater control measures identified in your SWPPP on your site map and list them below (add as many control measures as are implemented on-site). Carry a copy of the numbered site map with you during your inspections. This list will ensure that you are inspecting all required control measures at your facility. Identify if maintenance or corrective action is needed. If maintenance is needed, fill out section B of this template If corrective action is needed, fill out section G of this template Structural Control Measure Control Measure is Operating Effectively? If No, In Need of Maintenance, Repair, or Replacement? Maintenance or Corrective Action Needed and Notes 1 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 2 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 3 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 4 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 5 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 6 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 7 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed 8 Insert Control Measure Name Yes No Maintenance Repair Replacement Describe Maintenance and/or Corrective Actions Needed
Reason for Spill: Insert Reason for Spill/Leak Discharge to Waters of U.S.: Insert Whether Spill/Leak discharged to a Water of the U.S. Date: Insert Date Condition was Identified Immediate Actions: Insert Description of Immediate Actions Taken Actions within 14 Days: Insert Description of Actions Taken within 14 days of discovery 14 Day Infeasibility: If Applicable, document why it is infeasible to complete necessary installations or repairs within 14-day timeframe and describe schedule 45 Day Extension: If Applicable, document rationale sent to EPA for extension of 45 day timeframe Description of Condition: Insert description of condition trigering the need for corrective action For Spills and Leaks: Description of Incident: Insert Description Material: Insert description of material Date/Time: Insert Date/Time Amount: Insert Estimated Amount of Spill/Leak Location: Insert Location of Reason for Spill: Insert Reason for Spill/Leak Discharge to Waters of U.S.: Insert Whether Spill/Leak discharged to a Water of the U.S. Date: Insert Date Condition was Identified Immediate Actions: Insert Description of Immediate Actions Taken Actions Taken within 14 Days: Insert Description of Actions Taken within 14 days of discovery 14 Day Infeasibility: If Applicable, document why it is infeasible to complete necessary installations or repairs within 14-day timeframe and describe schedule 45 Day Extension: If Applicable, document rationale sent to EPA for extension of 45 day timeframe H. Benchmark Exceedances Date: Insert Date Pollutant Exceeded and Results: Insert Pollutant Name Quarter 1 (Sample date: Insert Sample Date) Result: Insert Sample Result Quarter 2 (Sample date: Insert Sample Date) Result: Insert Sample Result Quarter 3 (Sample date: Insert Sample Date) Result: Insert Sample Result Quarter 4 (Sample date: Insert Sample Date) Result: Insert Sample Result Average Result: Insert Value Benchmark Value: Insert Benchmark Value from 2015 MSGP