NCG160076_COMPLETE FILE - HISTORICAL_20131028

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE 0 HISTORICAL FILE
0 MONITORING REPORTS
DOC DATE ❑ o'?a13 �ytz
YYYYMMDD + `}'

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Energy, Mineral and Land Resources
Tracy E. Davis, PE, CPM Pat McCrory, Govenor
Director John E Skvarla, 111, Secretary
October 28, 2013
Mr. Gerry T. Smith
PO Box 948
Beaufort, NC 28516
Subject: COMPLIANCE EVALUATION INSPECTION
Ted & Todd's Marine Service
CoC # NCG 190076
Carteret County
Dear Mr. Smith:
On December 3, 2013, staff from the Wilmington Regional Office of the Division of Energy,
Mineral and Land Resources (DEMLR), conducted a site inspection for the tract/project known
as Ted & Todd's Marine Service located in Carteret County, North Carolina.
A review of the file by DEMLR staff revealed that the subject project is covered by NPDES
Stormwater General Permit — NCG190076.
Thank you for your assistance and cooperation during this inspection. As noted in the attached
inspection report, your site needs to prepare a stormwater pollution prevention plan (SPPP) and
conduct analytical (semi-annually) and qualitative monitoring (monthly) . Additionally, submit
analytical monitoring reports to Raleigh Central Office.
If you have any questions, comments, or need assistance with understanding any aspect of your
permit, please do not hesitate to contact me at [phone] or Brian. Larnbena ncdenngo .
Sincerely,
Brian Lambe
Environmental Specialist
DEMLR — Land Quality Section
Encl: NCG Addendum, NCG190076 Inspection Report, SPPP Template
DSIbl: G:II-RILQ1-NPDES\CarteretlNCG190076
Wilmington Regional Office
127 Cardinal Drive Extension, Wilmington, North Carolina 28405Phone: [phone] FAX: [phone]
An Equal Oppartun4 i Affirmative Acton Empgoyer

Page 2
Carteret -
ADDENDUM
The National Pollutant Discharge Elimination System (NPDES) program was established under
the federal Clean Water Act and then delegated the program to the NC Department of
Environment and Natural Resources (NCDENR). As of August 1, 2013, the Division of Energy,
Mineral and Land Resources (DEMLR) manages the implementation of this program for
NCDENR. The NPDES permitting program for stormwater discharges was established in 1990.
Phase I focuses on site and operations planning to reduce pollutant sources.
Through the NPDES permitting program, industrial facilities that fall into one of the subject ten
categories are required to obtain permit coverage under a general permit or an individual permit,
depending upon the facilities SIC code and the industrial activity occurring at the facility. There
are currently 19 active general stormwater permits in North Carolina. One condition that is
applicable to both the general permits and individual stormwater permits is the requirement to
develop and implement site -specific comprehensive stormwater pollution prevention plans
(SPPP). These plans are required to include a comprehensive evaluation of the site and
operations to reduce pollutant sources and prevent pollutant discharge.
Copies of the general permits and accompanying documents can be accessed from the following
webpage: littp://portal.ncdenr.org/web/Ir/npdes-stormwater#tab- Permit text, technical bulletins,
discharge monitoring forms, and a Notice of Intent [which is the application of for coverage
under a NPDES General Stormwater Permit] can be found at this web site.
The following items are a subset of permit requirements and are listed to assist you and help
bring your attention to certain permitting issues, process and condition requirements of your
permit. Please see the above mentioned web site in order to obtain a copy of the permit such that
you may fully comply with all the conditions therein. Failure to properly comply with
conditions of the permit, like those bulleted below, constitutes violations and are subject
civil penalty assessment of up to $25,000.00 per day.
• Industrial facilities that fall into one of the subject ten categories are required to obtain
permit coverage under a general NPDES stormwater permit or an individual NPDES
stormwater permit
• All persons desiring to have facilities covered by a General Permit must register with the
Division of Energy, Mineral and Land Resources (DEMLR) by the filing of a Notice of
Intent (NOI) and Applicable Fees.
• This Notice of Intent (NOI) must be submitted and a Certificate of Coverage issued prior
to any discharge of stormwater associated with the industrial activity, process
wastewater, and/or mine dewatering.
• Once the Notice of Intent is received, DEMLR will review and determine whether a
Certificate of Coverage (COC) may be issued. If this Certificate of Coverage is issued the
facility is covered by the General Permit. That is, the permittee is authorized to discharge
stormwater, process wastewater, and/or mine dewatering pursuant to the type of General
Permit until the permit expires or is modified or revoked.
• Any other point source discharge to surface water of the state is prohibited unless it is an
allowable non-stormwater discharge or is covered by another permit, authorization or
approval.

Page 3
Carteret
• There are currently 19 active general permits. Permit conditions vary accordingly;
however, most of the permits have following condition requirements (you must read your
entire permit to ensure full compliance);
o Development and compliance with the Stormwater Pollution Prevention Plan
o Collection, reporting, and recording of Analytical Monitoring
o Collection, reporting and recording of Qualitative Monitoring
o Collection, reporting and recording of Vehicle Maintenance Monitoring
o Records — Visual monitoring shall be documented and records maintained at the
facility along with the Stormwater Pollution Prevention Plan. Copies of the
analytical monitoring results shall also be maintained on -site. The Permittee
shall retain records of all monitoring information, including all calibration and
maintenance records and all original strip chart recordings for continuous
monitoring instrumentation, and copies of all reports required by this general
permit for a period of least 5 years for the date of the sample measurement, report
or application.
o Expiration — The permittee is not authorized to discharge after the expiration date
of the general permit. In order to receive automatic authorization to discharge
beyond the expiration date, the permittee shall submit forms and fees as are
required by the agency authorized to issue permits no later than 180-days prior to
expiration date. Any permittee that has not requested renewal at least 180 days
prior to expiration, or any permittee that does not have a permit after the
expiration and has not requested renewal at least 180 days prior to expiration, will
be subject to enforcement. Failure to renew your permit is a violation.
o Transfer — The Certificate of Coverage (COC) issued pursuant to this general
permit is not transferable to any person expect after notice to and approval by the
Director. The Director may require modification or revocation and reissuance of
the Certificate of Coverage to change the name and incorporate such other
requirements as may be necessary under the Clean Water Act. The Permit is
NOT transferable.
o Name Change, Closure or Facility Ownership change — Permittee is required to
notify the Division in writing in the event the permitted facility is sold or closed.
The Division of Energy, Mineral and Land Resources views changes of name or
ownership as a modification that requires the Director's approval and reissuance
of the permit. Name and ownership changes required you to complete a
Namelownership Change Form from the Division and mail it back to the along
with all appropriate information to the Division of Energy, Mineral and Land
Resources.
o Proper Operation and Maintenance is a requirement of the permit.

�r
Permit: NCG190076
SOC:
County: Carteret
Region: Wilmington
Compliance Inspection Report
Effective: 10/01/09 Expiration: 09/30/14 Owner: Gerry T Smith Inc DBA Ted & Todd Marine
Service
Effective: Expiration: Facility: Ted & Todds Marine Service - Beaufort
464 Old Causeway Rd
Contact Person: Gerry T Smith Title: President
Directions to Facility:
UA 70E to Radio Island. Turn right to go to Piver's Island. Then left on Causeway Road.
System Classifications:
Primary ORC: Certification:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Beaufort NO 28516
Phone: [phone]
Phone:
Inspection Date: 12/03/2013 Entry Time: 11:00 AM Exit Time: 11:45 AM
Primary Inspector: Brian P Lam f2. Phone:
Secondary Inspector(s): I
Reason for Inspection: Follow-up Inspection Type: Technical Assistance
Permit Inspection Type: Ship and Boat Building Stormwater Discharge COC
Facility Status: 0 Compliant ■ Not Compliant
Question Areas:
0 Storm Water
(See attachment summary)
Page: I

Permit: NGG190076 Owner • Facility: Gerry T Smith Inc DBA Ted & Todd Marine Service
�1�
Inspection Date: 12/03/2013 Inspection Type: Technical Assistance Reason far Visit: Follow-up
Inspection Summary:
Met with Mr. Smith to discuss development of a SPPP.
Page: 2

Permit: NCG190076 Owner - Facility: Gerry T Smith Inc DBA Ted & Todd Marine Service
Inspection Date: 12/0312013 Inspection Type: Technical Assistance
Reason for Visit:
Follow-up
Stormwater Pollution Prevention Plan
Yes
No
NA
NE
Does the site have a Stormwater Pollution Prevention Plan?
❑
■
❑
❑
# Does the Plan include a General Location (USGS) map?
Q
■
❑
❑
# Does the Plan include a "Narrative Description of Practices"?
❑
■
❑
❑
# Does the Plan include a detailed site map including outfall locations and drainage areas?
❑
■
❑
❑
# Does the Plan include a list of significant spills occurring during the past 3 years?
Cl
■
❑
❑
# Has the facility evaluated feasible alternatives to current practices?
❑
■
❑
❑
# Does the facility provide all necessary secondary containment?
n
■
n
n
# Does the Plan include a BMP summary?
❑
■
❑
❑
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
Cl
■
❑
❑
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
❑
■
Cl
rl
# Does the facility provide and document Employee Training?
❑
■
❑
❑
# Does the Plan include a list of Responsible Party(s)?
❑
■
❑
❑
# Is the Plan reviewed and updated annually?
❑
■
❑
❑
# Does the Plan include a Stormwater Facility Inspection Program?
❑
■
❑
❑
Has the Stormwater Pollution Prevention Plan been implemented?
❑
■
❑
❑
Comment: Permittee shall be developing SPPP in the coming months.
Qualitative Monitoring
Yes
No
NA
NE
Has the facility conducted its Qualitative Monitoring semi-annually?
❑
■
❑
❑
Comment: Monitoring should start according to permit requirements.
Analytical Monitoring Yes No NA NE
Has the facility conducted its Analytical monitoring? ❑ ■ ❑ ❑
# Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas? ❑ ❑ ■ Cl
Comment: Monitoring should begin according to permit requirements.
Permit and Outfalls
Yes
No
NA
NE
# Is a copy of the Permit and the Certificate of Coverage available at the site?
❑
■
❑
❑
# Were all outfalis observed during the inspection?
❑
■
❑
❑
# If the facility has representative outfall status, is it properly documented by the Division?
❑
❑
■
❑
# Has the facility evaluated all illicit (non stormwater) discharges?
❑
■
❑
❑
Comment: Permittee should develop a SPPP to include outfall documentation and
develop a sampling plan.
Page: 3

Permit: NCG190076
SOC:
County: Carteret
Region: Wilmington
Compliance Inspection Report
Effective: 10/01/09 Expiration: 09/30/14 Owner: Gerry T Smith Inc DBA Ted & Todd Marine
Service
Effective: Expiration: Facility: Ted & Todds Marine Service - Beaufort
464 Old Causeway Rd
Contact Person: Gerry T Smith Title: President
Directions to Facility:
UA 70E to Radio Island. Turn right to go to Piver's Island. Then left on Causeway Road.
System Classifications:
Primary ORC: Certification:
Secondary ORC(s):
On -Site Representative(s):
Related Permits:
Beaufort NC 28516
Phone: [phone]
Phone:
Inspection Date: 10/28/2013 Entry Time: 01:00 PM Exit Time: 01:30 PM
Primary Inspector: Brian P Lambe Phone.
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Ship and Boat Building Stormwater Discharge COC
Facility Status: ❑ Compliant ■ Not Compliant
Question Areas:
Storm Water
(See attachment summary)
Page: 1

Permit: NCG190076 Owner - Facility: Gerry T Smith Inc DBA Ted & Todd Marine Service
Inspection Date: 1012812013 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Mr. Smith was on site. He was unaware of permit requirements including SPPP and monitoring. Work towards gaining
compliance must begin immediately. Please contact this office if you have any questions.
Page: 2

Permit: NCG190076 Owner -Facility: Gerry T Smith Inc DBA Ted & Todd Marine Service
Inspection Date: 10/28/2013 Inspection Type: Compliance Evaluation
Reason for Visit:
Routine
Stormwater Pollution Prevention Plan
Yes
No
NA
NE
Does the site have a Stormwater Pollution Prevention Plan?
n
■
n
n
# Does the Plan include a General Location (USGS) map?
n
■
n
n
# Does the Plan include a "Narrative Description of Practices"?
0
■
n
0
# Does the Plan include a detailed site map including outfall locations and drainage areas?
n
■
❑
n
# Does the Plan include a list of significant spills occurring during the past 3 years?
n
■
❑
❑
# Has the facility evaluated feasible alternatives to current practices?
n
■
n
n
# Does the facility provide all necessary secondary containment?
n
■
n
n
# Does the Plan include a BMP summary?
n
■
n
0
# Does the Plan include a Spill Prevention and Response Plan (SPRP)?
n
®
❑
I_l
# Does the Plan include a Preventative Maintenance and Good Housekeeping Plan?
n
■
n
n
# Does the facility provide and document Employee Training?
❑
■
n
n
# Does the Plan include a list of Responsible Party(s)?
n
n
n
# Is the Plan reviewed and updated annually?
n
■
n
n
# Does the Plan include a Stormwater Facility Inspection Program?
n
■
n
n
Has the Stormwater Pollution Prevention Plan been implemented?
❑
■
n
n
Comment: Prepare a Stormwater Pollution Prevention Plan and submit documentation
to this office.
Qualitative Monitori
Has the facility conducted its Qualitative Monitoring semi-annually?
Comment: Qualitative Monitoring is not being conducted.
Analytical Monitoring
Has the facility conducted its Analytical monitoring?
# Has the facility conducted its Analytical monitoring from Vehicle Maintenance areas?
Comment: Analytical Monitoring is not being conducted.
Permit and Outfalls
# Is a copy of the Permit and the Certificate of Coverage available at the site?
# Were all outfalls observed during the inspection?
# If the facility has representative outfall status, is it properly documented by the Division?
# Has the facility evaluated all illicit (non stormwater) discharges?
Comment: Actions have not been taken by permit holder regarding this permit.
Yes No NA NE
Yes No NA NE
n■nn
n■❑n
Yes No NA NE
n■nn
n■nn
❑n■n
n■nn
Page: 3

�OF W A TE9Q Michael F. Easley, Governor
�0 G William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Q Alan W. Klimek, P.E. Director
Division of Water Quality
November 17, 2006 NOV Y 12006
Mr. Gerry T. Smith
P.O. Box 948
Beaufort, NC 28516
Subject: General Permit No. NCG190000
Ted & Todd's Marine Service
COC No. NCGt90076
Carteret County
Dear Mr. Smith:
In accordance with your application fora discharge permit received on September 20,
2006, we are forwarding herewith the subject certificate of coverage to discharge under the
subject state — NPDES general permit. This permit is issued pursuant to the requirements of
North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the US Environmental Protection Agency dated May 9, 1994 (or as subsequently
amended).
Please take notice that this certificate of coverage is not transferable except after notice to
the Division of Water Quality. The Division of Water Quality may require modification or
revocation and reissuance of the certificate of coverage.
This permit does not affect the legal requirements to obtain other permits which may be .
required by the Division of Water Quality or permits required by the Division of Land
Resources, Coastal Area Management Act or r any other federal or local governmental permit that
may be required.
If you have any questions concerning this permit, please contact Bethany Georgoulias at .
telephone number [phone] ext. 529.
Sincerely,
0RiG1NAi SIGKI
MICHEAL F Rl NDAL-�
Alan W. Klimek, P.E.
cc: Wilmington Re gional_Office
Central Files
S tormwater. Permitting Unit Files
. Non`hCarolina
Naturalljl
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: www.newater ualit r Location: 512 N. Salisbury St. Raleigh, NC 27604 Fax [phone]
An Equal OpportunitylAHirmative Action Employer— 50% Recyded110% Post Consumer Paper

STATE -OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
GENERAL PERMIT NO. NCG190000
CERTIFICATE OF COVERAGE No. NCG190076
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM.
In compliance with the provision of North Carolina General Statute 143-215.1, other Iawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Gerry T. Smith
is hereby authorized to discharge stormwater from a facility located at
Ted and Todd's Marine Service
464 Old Causeway Road
: Beaufort
Carteret County
to receiving waters designated as Beaufort Channel, a class SA HQW water in the White Oak
River Basin, in accordance with the effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, II, III, IV, V, and VI of General Permit No. NCG190000 as
attached.
This Certificate of Coverage shall become effective November 17, 2006.
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day November 17, 2006. CRiGINALFIGNEDBY
B :
WALL
for Alan W. Klimek, P.E., Director
Division of Water Quality
By the Authority of the Envirorunental Management Commission

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a7 '
Latitude:34'43'19" NCG190076 Facility
r y ,
Longitude: 76°40'17" Ted & Todd's Marine,
County: Carteret • Location
Service
Stream Class: SA HQW .
Receiving Stream: Beaufort Channel NorthSub-basin: 03-05-03 (White Oak River Basin) SCALE 1:24,000

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
o �
Industrial SWPPP Template
Introduction
To help you develop a SWPPP that is consistent with the 2008 MSGP, the U.S Environmental Protection
0 Agency (EPA) has created this Industrial SWPPP Template (or, "the Template"). Use of the Template will
help ensure that your SWPPP addresses all the necessary elements required in Part 5 of the 2008 MSGP.
Before completing the Template, make sure you read and understand the requirements in the 2008 MSGP.
A copy of the MSGP is available at www.epa.gov/npdes/stormwater/msgp.
Using the Industrial SWPPP Template
Tips for completing the Template:
• This Template is designed for use by all facilities eligible for coverage under the 2008
MSGP. The Template is NOT tailored to your individual industrial sector. Depending on
which industrial sector you fall under (see Appendix D of the 2008 MSGP) and on where
your facility is located (see Appendix C of the 2008 MSGP), you will need to address
additional SWPPP requirements outlined in Part 8 and/or Part 9 of the permit, respectively.
• Complete a SWPPP before submitting your Notice of Intent (NOI) for permit coverage.
• Each section includes "instructions" and space for your facility's specific information.
You should read the instructions for each section before you complete that section.
• The Template was developed in Microsoft Word so that you can easily add tables and
additional text. Some sections may require only a brief description while others may
require several pages of explanation.
• To make it easier to complete, the Template generally uses blue text where the operator is
expected to enter information.
EPA notes that while EPA has made every effort to ensure the accuracy of all instructions and guidance
contained in the Template, the actual obligations of regulated industrial facilities are determined by the
relevant provisions of the permit, not by the Template, In the event of a conflict between the Template and
any corresponding provision of the MSGP, the permit controls. EPA welcomes comments on the Template
at any time and will consider those comments in any future revision of this document.
EPA Industrial SWPPP Template, January 13, 2009

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
Stormwater Pollution Prevention Plan
for:
Insert Facility Name
Insert Facility Address
insert City, State, Zip Code
Insert Facility Telephone Number (if applicable)
SWPPP Contact(s):
Insert Facility Operator
Insert Name
Insert Address
Insert City, State, Zip Code
Insert Telephone Number
Insert Fax/Email
SWPPP Preparation Date:
EPA Industrial SWPPP Template, January 13, 2009

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
Contents
SECTION 1: FACILITY DESCRIPTION AND CONTACT INFORMATION......................................................1
1.1
Facility Information.................................................................................................................
1
1.2
Contact Information/Responsible Parties................................................................................
2a
1.3
Stormwater Pollution Prevention Team..................................................................................
;
1.4
Activities at the Facility.........................................................................................................
3�
1.5
General Location Map
1.6
Site Map ...................................................... ... ................. .... ......................................... I......
5-5
SECTION
2: POTENTIAL POLLUTANT SOURCES.....................................................................................66
2.1
Industrial Activity and Associated Pollutants...........................................................................
66
2.2
Spills and Leaks...................................................................................................................
7-7
2.3
Non-Stormwater Discharges Documentation..........................................................................
7-7
2.4
Salt Storage........................................................................................................................
88
2.5
Sampling Data Summary ......................................................................................................
88
SECTION
3: STORMWATER CONTROL MEASURES.................................................................................88
3.1
Minimize Exposure...............................................................................................................
9-9
3.2
Good Housekeeping.............................................................................................................
99
3.3
Maintenance........................................................................................................................9-9
34
Spill Prevention and Response 104-0
..........................................................................................
.............. _
3.5 Erosion and Sediment Controls.............................................................. ............. 104-0
3,6 Management of Runoff.....................................................................................................
104-0
3.7 Salt Storage Piles or Piles Containing Salt.........................................................................
1144
3.8 MSGP Sector -Specific Non -Numeric Effluent Limits............................................................
1 144
3.9 Employee Training...........................................................................................................
1 144
3.10 Non-Stormwater Discharges.............................................................................................
1144
3.11 Waste, Garbage and Floatable Debris .................... ..........................
124-22
3.12 Dust Generation and Vehicle Tracking of Industrial Materials ...............................................
124-2-
SECTION 4: SCHEDULES AND PROCEDURES FOR MONITORING.....................................................134-3
SECTION 5: INSPECTIONS.......................................................................................................................154-5
SECTION 6: DOCUMENTATION TO SUPPORT ELIGIBILITY CONSIDERATIONS UNDER OTHER
FEDERALLAWS.......................................................................................................................................164
6.1 Documentation Regarding Endangered Species.................................................................
164-6
6.2 Documentation Regarding Historic Properties.....................................................................
16 -6
6.3 Documentation Regarding NEPA Review (if applicable)......................................................
16"
SECTION 7: SWPPP CERTIFICATION.....................................................................................................164-6
SECTION 8: SWPPP MODIFICATIONS....................................................................................................1848
SWPPP ATTACHMENTS...........................................................................................................................194-9
Attachment A - General Location Map
Attachment B - Site Maps
Attachment C - 2008 MSGP
EPA Industrial SWPPP Template, January 13, 2009 ii

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAML and DATE
SECTION 1: FACILITY DESCRIPTION AND CONTACT INFORMATION
1.1 Facility Information
irx 5 � �. a7- . w y 'I "j.
is
r InstrdctionS
� �,. 3 ��s.. a. r.�,�i" � �r�:'��3 q,�� �,} q�3�1,� i� y.i; '� .ry�''.ilf� ��]sP'�'��,•x �?rs..', 3 ems. »y t iq"�?F� "i ii� a x ,.>�, � , f �� '+,iv n, � ,
RYou will need the information from this section to complete youK N01 3 q s ,
! �i �r 3 7�' 'ems '�qiz s S- nra q.v.-i a i ,i;.. N,.� ie3.s a °, >. _: 3 C
For further instruction refer to the 2008 MSGP�NOI form and mstructlons speciflcallysections Cand D of„
�l�y5 l34 i,.. , ti x,, - i r� e ! .-+ 94 � 3 Wt _ 7 - 7 � ? �
the 1VOl �A copy of the 2008 MSGP'NOI is available at www epa govinpdeslstormwaterl'msgp (Appendix
�G of,the permit)i�,f1j0' 3 1 ;!s 3 � �,�, z;�, „ §, �� 00t­ `!x
x.Y...,,,. F e.�1 .r-., p au ,•- .ice. n... r •-='r
3 ; Detailed hf6r t& on determining your site s latitude arzd longitude can be found at Mj , �' G `,
www epa govinpdeslstormwaterllatlong.,, , ,, ,�#�l ,s r S , i � _a 3iti � � i r,vi
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und,Youmusinclude acopyothe2008MSGora reference acopycabeP efo
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'
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4.n'iO` 111I1i '" .n ..�-=i , '" '' i � f, 1 f1 i 3f10
s
Facility Information
Name of Facility: _
Street;
City: State: ZIP Code:
County or Similar Subdivision:
Permit Tracking Number: (if covered under a previous permit)
Latitude/Longitude (Use one of three possible formats, and specify method)
Latitude: Longitude:
1. _ _ ° _ _' _ _" N (degrees, minutes, seconds) 1. _ _ ° _ _' _ _" W (degrees, minutes, seconds)
2. _ _ ° _ _ _ _' N (degrees, minutes, decimal) 2. _ _ ° _ _ _ —'W (degrees, minutes, decimal)
3. _ _ . _ _ _ _ ° N (decimal) 3, _ _ . _ _ _ _ ° W (decimal)
Method for determining latitude/longitude (check one),
❑ USGS topographic map (specify scale: ) ❑ EPA Web site ❑ GPS
❑ Other (please specify):
Is the facility located in Indian Country? ❑ Yes ❑ No
If yes, name of Reservation, or if not part of a Reservation, indicate "not applicable."
Is this facility considered a Federal Facility? ❑ Yes ❑ No
Estimated area of industrial activity at site exposed to stormwater: (acres)
Discharge Information
EPA Industrial SWPPP Template, January 13, 2009 1

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
Does this facility discharge stormwater into an MS4? ❑ Yes ❑ No
If yes, name of MS4 operator:
Name(s) of water(s) that receive stormwater from your facility
Are any of your discharges directly into any segment of an "impaired" water? ❑ Yes ❑ No
If Yes, identify name of the impaired water (and segment, if applicable):
Identify the pollutant(s) causing the impairment:
For pollutants identified, which do you have reason to believe will be present in your discharge?
For pollutants identified, which have a completed TMDL?
Do you discharge into a receiving water designated as a Tier 2 (or Tier 2.5) water? ❑ Yes ❑ No
Are any of your stormwater discharges subject to effluent guidelines? ❑ Yes ❑ No
If Yes, which guidelines apply?
Primary SIC Code or 2-letter Activity Code:
(refer to Appendix D of the 2008 MSGP)
Identify your applicable sector and subsector:
1.2 Contact Information/Responsible Parties
Instructions:
— List the facility operator(s), facility owner, and 24 hour emergency contact. Indicate respective
responsibilities, where appropriate.
You will need the information from this section of the SWPPP Template for your N01.
Refer to Section B of the NO] instructions (available in Appendix G of the 2008 MSGP).
Facility Operator (s):
Name- Insert Name
Address: Insert Address
City, State, Zip Code: Insert City, State, Zip Code
Telephone Number: Insert Telephone Number
Email address: Insert email address
Fax number: Insert fax number (optional)
Facility Owner (s):
Name: Insert Name
Address: Insert Address
City, State, Zip Code: Insert City, State, Zip Code
EPA Industrial SWPPP Template, January 13, 2009 2

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
Telephone Number: Insert Telephone Number
Email address: Insert email address
Fax number- Insert fax number (optional)
SWPPP Contact:
Name: Insert SWPPP Contact Name
Telephone number: Insert Telephone Number
Email address: Insert email address
Fax number: Insert fax number (optional)
1.3 Stormwater Pollution Prevention Team
Instructions (see 2008 MSGP Part 5.1.1):
- Identify the staff members (by name or title) that comprise the facility's stormwater pollution prevention team
as well as their individual responsibilities.
— °Your stormwater pollution prevention team is responsible for assisting the facilit
y manager in developing and ;
revising the facility's SWPPP, implementing and maintaining control measures/BMPs, and taking corrective.
actions where required. Each member of the stormwater pollution prevention team must have ready access
to either an electronic or.paper copy of applicable portions of the MSGP and your SWPPP.
Staff Names
Individual Responsibilities
Insert name of SWPPP team
member
Insert explanation of that staff person's responsibilities relating to
compliance with the permit
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary)
[Repeat as necessa l
(Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
1.4 Activities at the Facility
Instructions (see 2008 MSGP Part 5.1.2):
Provide a general description of the nature of the industrial activities at your facility.'
Insert text here
EPA Industrial SWPPP Template, January 13, 2009 3

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME: and DATE
1.5 General Location Map
Instructions (see 2008 IVISGP Part 5.1.2):
— Provide a general location map (e.g., U.S. Geological Survey (USGS) quadrangle map) with enough detail to
identify the location of your facility and all receiving waters for your stormwater discharges (include as
Attachment A of this SWPPP Template).
Include a copy of the general location map for this facility in Attachment A.
EPA Industrial SWPPP Template, January 13, 2009 4

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAML and DATES
1.6 Site Map
Instructions (see 2008 MSGP Part 51 2) `
Include,a map showing the following information. The site map should be included as Attachment
of this SWPPP Template.
■ the size of the property In acres;
■ the location and extent of significant structures and impervious surfaces;
direct . _ ions of stormwater flow (use arrows);
■ locations of all existing structural control measures;
■ locations of all receiving waters in the Immediate vicinity of your facility, indicating if any of the
waters are impaired and, if so, whether the waters have TMQLs established for them;
■ '' locations of"all, stormwater'conveyances'including ditches, pipes,.arid swales;.
locations of potential pollutant sources. identifed.underMSGP, Part 5.1.3.2;
locations Where -sign: ificant spills or leaks identified under MSGP, Part 5.1:3.3 have occurred;
locations of all ston.lwater monitoring points;
■ locations.of stormwater inlets and outfalls-with a -unique identification'code for each outfall
(e.g., Outfall No..1, No. 2, etc), indicating if you are treating one or more.-outfalls as
"substantially identical" under, MSGP; Parts 4:2.3; 5.1.52, and 6.1.1, and an approximate
outline of the areas draining to each outfall;
■ municipal separate storm sewer systems, where your stormwater discharges to them;
■ locations and descriptions of all non-stormwater discharges identified under.. MSGP, Part
2.1.2.10;
■ locations of the following activities where such activities are exposed to precipitation:
o fueling stations;
o vehicle and,equipment maintenance and/or cleaning areas;
o loading/unloading'areas,s
ge, or disposal of wastes;
o liquid story a tanks; treatment, story - o locations used for the t
q g
o processing and storage areas;
o immediate access roads and rail lines' used or traveled by carriers of raw materials, als,
man ufactured.products,"waste material, orby-products used or created by the,'facility;
o transfer areas for substances in bulk;
o machinery; and:
■ locations and sources of run-on to'your;site from adjacent property that contains significant
quantities'of pollutants.
Include a copy of the site map for this facility in Attachment B.
EPA Industrial SWPPP Template, January 13, 2009 5

Stormwater Pollution Prevention Plan (SWPPP)
INSI]RT FACILITY NAME and DATE
SECTION 2: POTENTIAL POLLUTANT SOURCES
Instructions (see 2008 MSGP Part 5.1.3):
— In this section, you are required to describe areas at your facility where industrial materials or activities are
exposed to stormwater or from which allowable non-stormwater discharges are released.
2.1 Industrial Activity and Associated Pollutants
Instructions (see 2008 MSGP Parts 5.1.3.1 and 5.1.3.2):
Include a list of industrial activities exposed to stormwater (e.g., material storage; equipment/vehicle fueling,
maintenance, and cleaning;. cutting steel beams) and the pollutants or pollutant constituents (e.g., motor oil,
fuel, battery acid, and cleaning solvents) associated with these activities.
In your list of pollutants associated with your industrial activities, include all significant materials that have
been handled, treated, stored, or disposed, and that have been exposed to stormwater in the 3 years prior to
the date you prepare your SWPPP.
Industrial Activi
Associated Pollutants
Insert specific industrial activity
Insert names of pollutants or pollutant constituents
that could be associated with this activity and
released in stormwater
Repeat as necessary]
Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
[Repeat as necessary]
Repeat as necessary]
(Repeat as necessary]
[Repeat as necessary]
EPA Industrial SWPPP Template, January 13, 2009 6

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAMES and ELATE
2.2 Spills and Leaks
Instructions (See 2008 MSGP Part 5.1.3.3):
— Include the following in this section:
o Potential spills and leaks: A description of where potential'spills and leaks could occur at your
site that could contribute pollutants to your stormwater discharge, and specify which outfall(s) are
likely to be affected by sudh.spills and leaks.
o Past spills and leaks: A description of significant spills and.leaks in the past 3 years of oil or toxic
or hazardous pollutants that actually occurred at exposed areas, or that drained to a stormwater
conveyance.
g p leaks inc — Note: Significant spills and le lode, but are not fimifed to, releases of oil or hazardous substances in
excess of quantities that are reportable under CWA Section 311(see 40 CFR:110.6 and 40 CFR417.21) or.
Section 102 of the Comprehensive Environmental Response, Compensation and Liability Act (CERCLA), 42
USC §9602.
Areas of Site Where Potential Spills/Leaks Could Occur
Location Outfalls
Insert description of area where spill/leak could occur Specify which outfall(s) would be
affected
[Repeat as necessary] [Repeat as necessary]
[Repeat as necessary] [Repeat as necessary]
[Repeat as necessary] I [Repeat as necessary]
Description of Past Spills/Leaks
Date Description Outfalls
Insert date of Insert description of spill/leak (where it occurred, what Specify which outfall(s)
spill/leak happened, types of pollutants, extent of damage) were affected
[Repeat as [Repeat as necessary] [Repeat as necessary]
[Repeat as I [Repeat as necessary]
[Repeat as I [Repeat as necessary]
necessary]
2.3 Non-Stormwater Discharges Documentation
[Repeat as necessary]
[Repeat as necessary]
EPA Industrial SWPPP Template, January 13, 2009 7

Stortnwater Pollution Prevention Plan (SWPPP)
1NSER'r FACILITY NAME and DATE
• Date of evaluation- Insert the date(s) of your evaluation.
• Description of the evaluation criteria used: Describe the method you used to conduct your
evaluation and to determine for each non-stormwater sources whether it is prohibited or allowed
under the permit.
• List of the outfalls or onsite drainage points that were directly observed during the evaluation; Insert
outfalls/drainage points observed,
• Different types of non-stormwater discharge(s) and source locations: Describe types of non-
stormwater discharges observed and the corresponding outfall or drainage point.
• Action(s) taken, such as a list of control measures used to eliminate unauthorized discharge(s), if
any were identified. For example, a floor drain was sealed, a sink drain was re-routed to sanitary,
or an NPDES permit application was submitted for an unauthorized cooling water discharge;
Describe actions taken to eliminate unauthorized non-stormwater discharges and the
corresponding outfall/drainage point affected.
2.4 Salt Storage
Instructions (see 2008 MSGP Part 5.1.3.5):
Document the location of any storage piles containing salt used for deicing or other commercial or industriat
purposes.
Note: You will be asked additional questions concerning salt storage in„Section 3.7 of this SWPPP template,
below.
Insert description of the location of any storage piles containing salt.
2.5 Sampling Data Summary
Instructions (See 2008'MSGP Part 5.1.3.6):
— Sumfiarize all stormwater sampling data collected from your permitted outfalls during the previous permit
term:
Insert summary of stormwater sampling data collected for the past permit, and/or attach discharge
monitoring reports or laboratory results.
SECTION 3: STORMWATER CONTROL MEASURES
( P Parts'5.1.4.1 and22.1,2) Instructions See 2008 MSG - _
In Sections_.3.1 1.12 of;this SWPPP template, you are asked to describe the-stormwater control measures
that:you have installed at your site to meet each.of the permifs "non -numeric effluent. limits" in Part 2.1.2'of
the 2008 MSGP
EPA Industrial SWPPP Template, January 13, 2009 8

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
3.1 Minimize Exposure
:
Instructions (see 2008 MSGP Part 2.1.2.1):
Describe any structural controls or practices used to minimize the exposure of industrial activities to rain,
snow; snowmelt, and runoff. Describe where the controls or practices are being implemented at your site.
INSERT DESCRIPTION OF CONTROL_ MEASURES HERE.
3.2 Good Housekeeping
Instructions (see 2008 MSGP Parts 2.1.2.2 and 5.1.5.1):
Describe any practices you are implementing to keep exposed areas of your site clean. - Describe where each
practice is being implemented at your site. Include here your schedule for (1) regular pickup and disposal of
waste matenals,.and (2) routine inspections for leaks and of the condition' of drums, tanks, and containers.
INSERT DESCRIPTION OF CONTROL MEASURES HERE,
3.3 Maintenance
Instructions'(see 2008 MSGP Parts 2.1.2.3 and 5.1.5.1):
Describe procedures (1) to maintain industrial equipment so that spillslleaks are avoided, and°(2) to maintain
any of your site's control measures in effective operating condition. include the schedule you will follow for`
such maintenance activities. Describe where each applicable procedure is being implemented at the site.
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
EPA Industrial SWPPP Template, January 13, 2009 9

Storrnwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
3.4 Spill Prevention and Response
Instructions (see 2008 MSGP Parts 2.1.2.4 and 5.1.5.1):
-- Describe,any structural controls or procedures used to minimize the potential for leaks, spills, and other
releases. You must implement the following at a minimum:
Procedures for plainly labeling containers (e.g:, "Used Oil," "Spent Solvents," "Fertilizers and
Pesticides," etc.) that could be susceptible to spillage or leakage to encourage proper handling and
facilitate rapid response if spills or leaks occur;
■ Preventative measures such as bamers between material storage and traffic areas, secondary
containment provisions, and procedures for material -storage and handling;
Procedures for expeditiously stopping, containing, and cleaning up leaks, spills, and other releases; and
Procedures for notification of.appropriate facility personnel, emergency response agencies, and
regulatory agencies.
Describe where each control is to be located or where applicable procedures will be implemented.
— Note: Some facilities may be required to develop a Spill Prevention Control and Countermeasure `(SPCC)
plan under a separate regulatory. program (40 CFR.112). If you are required to develop an SPCC plan, or
you already have one, you should include references to the relevant requirements from your plan.
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
3.5 Erosion and Sediment Controls
Instructions (see 2008 IVISGP Part 2.1.2.5):
Describe structural or non-structural controls used at your site to stabilize exposed areas and contain runoff to
minimize onsite erosion and potential offsite discharges of sediment. Note: You must at a minimum implement
flow velocity dissipation devices at outfalls and discharge channels. Describe the location at your site where
each control will be implemented:
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
3.6 Management of Runoff
Instructions (See 20WIVISGP Paint 2.1.2.6):
Describe controls used at your site to divert, infiltrate, reuse, -contain, or.otherwise reducestormwater runoff..,
Describe the location ,at your srte, yr ere. each control will be implemented
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
EPA Industrial SWPPP Template, January 13, 2009 10

Storrnwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
3.7 Salt Storage Piles or Piles Containing Salt
Instructions see 2008 MSGP Part 2.1.2.7
If applicable, describe structures afyoursite that either cover or enclose salt storage piles or piles containing salt,
or that prevent the discharge of stonnwater from such piles'..Also, describe any controls or procedures: used -to
minimize exposure resulting from adding to or removing materials from the pile. Describe the. location at your site
where each control andlorprocedure will be implemented.
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
3.8 MSGP Sector -Specific Non -Numeric Effluent Limits
Instructions (see 2008 MSGP Part 2.1.2.8):
Describe any or procedures
— y p res that will be used at your site to comply with any sector -specific
requirements that apply to you in Part 8 of the 2008 MSGP.'- Describe'the location at your site where
each control and/or procedure will be implemented.
Note: Sector -specific effluent limits apply. to Sectors A, E, F, G, H, ,I, L, M, N, 0, P, Q, R, S, T, U, V, X,
Y, Z, and AA. ;
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
3.9 Employee Training
Instructions (see 2008 MSGP Parts 2.1.2.9 and 5.1.5.1):
Describe your plan for training the employees who work in areas where industrial materials or activities are
exposed to stormwater, or who are responsible for implementing activities necessary to meet -the conditions of
the 2008 MSGP, including all.members of your Pollution Prevention Team. Included in your description must be
the frequency of training (note: recommended at least one time per year),and the schedule you will follow.
INSERT DESCRIPTION OF PLAN FOR TRAINING APPLICABLE STAFF HERE.
3.10 Non-Stormwater Discharges
Instructions (see.2008 MSGP 2.1:2.10):
Describe how.you eliminated any unauthorized non-stormwater discharges.a#your site. The unauthorized non-
storinwater m not
the 008 MSGPh !Vote-arges ' If !this ectionissal ady addressed 4 your documentation for Section et l3 of the SWPPP
template; you can,simply include a cross-reference to that section of your SWPPP.
INSERT DESCRIPTION OF YOUR APPROACH TO ELIMINATING UNAUTHORIZED NOW
STORMWATER DISCHARGES HERE.
EPA Industrial SWPPP Template, January 13, 2009 11

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
3,11 Waste, Garbage and Floatable Debris
Instructions (see 2008 MSGP Part 2.1.2.11):
Describe controls and procedures that will be used at your site to minimize discharges of waste, garbage, and
floatable debris. Describe the location at your site where each control and/or procedure will be implemented.
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
3,12 Dust Generation and Vehicle Tracking of Industrial Materials
Instructions (see 2008 MSGP Part 2.1.2.12):
Describe controls and procedures you will use at your site to minimize the generation of dust and off -site tracking
of raw, final, or waste materials. Describe the location at your site where each control and/or procedures will be
implemented.
INSERT DESCRIPTION OF CONTROL MEASURES HERE.
EPA Industrial SWPPP Template, January 13, 2009 12

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
SECTION 4: SCHEDULES AND PROCEDURES FOR MONITORING
Instructions (see 2008 MSGP Part 5.1.5.2):
— Describe your procedures for conducting the five types of analytical monitoring specified by the MSGP,
where applicable to.your facility, including:
■ Benchmark monitorin 2008 MSGP, Part6.2.1 and relevant requirements in Part 8 and/or Part 9);
Effluent limitations guidelines monitoring (2008 MSGP; `Part 6.2.2 and'rele' nt requirements in Part $);
State- or Tribal -specific monitoring (2008 MSGP, Part 6.2.3 and relevant requirements in Part 9);
■ Impaired waters monitoring (2008 MSGP, Part 6.2.4); and
■ Other monitoring as b required 2008 MSGP, Part 6.2.5).
q Y EPA ( -
Depending on the type of facility you operate; and the monitoring requirements to which you are subject,`you
must collect and analyze stormwater samples and document monitoring activities consistent with the
procedures described in 2008 MSGP, Part 6 and Appendix B, Subsections 10 -12, and any additional
sector -specific or State/Tribal-specific requirements in 2068 MSGP, Parts 8 and 9, respectively. Refer to
2008 MSGP, Part 7-for reporting,and recordkeeping requirements. Note: All monitoring must be conducted
in accordance with the relevant sampling,and analysis requirements at-40,CFR Part 136. include in your
description procedures for ensuring compliance with these.requirements.
If you are invoking the exception for inactive and unstaffed sites for benchmark monitoring, you must include
in your SWPPP the information to support this claim as required by 2008 MSGP, Part 6.2.1.3.
Y p y p y . g requirements
If you Ian to use the identical outfall exce tion for our benchmark monitoring re' ' — in
2008 MSGP, Part 6.2.1 and/or your quartedy.visual assessment requirements in 2008 MSGP, Part 4.2.3 '-
you must include the following documentation:, -
Location of each;of the substantially identical outfalls; .
Description of the general industrial activities conducted in the drainage area of each outfall;
• Descriptioh of the control measures implemented in the drainage area of each outfall; .
■ Description of the exposed materials located in the drainage area of each outfall that are likely to be
significant contributors of.pollutants to stormwater discharges;
An estimate:of the runoff .coefficient of the drainage areas (low.= under 40%; medium = 40 to 65%; high, -
above .65%); and
Why the outfalls are�e'xpected to discharge substantially identical effluents:
For each type of monitoring, your SWPPP must include a description of:
1. Sample Location(s), Describe where samples will be collected, including any determination that two or
more outfalls are substantially identical. INSERT TEXT HERE
2, Pollutant Parameters to be Sampled. Include a list of the pollutant parameters that will be sampled and
the frequency of sampling for each parameter. INSERT TEXT HERE
3. Monitoring Schedules. Include the schedule you will follow for monitoring your stormwater discharge,
including where applicable any alternate monitoring periods to be used for facilities in climates with irregular
stormwater runoff (2008 MSGP, Part 6.1.6). INSERT TEXT HERE
EPA Industrial SWPPP Template, January 13, 2009 13

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
4. Numeric Limitations. List here any pollutant parameters subject to numeric limits (effluent limitations
guidelines), and which outfalls are subject to such limits. Note that numeric limits are only included for
Sectors A, C, D, E, J, K, L, and 0. INSERT TEXT HERE
5. Procedures. Describe procedures you will follow for collecting samples, including responsible staff who will
be involved, logistics for taking and handling samples, laboratory to be used, etc. INSERT TEXT HERE
Note: It may be helpful to create a table with columns corresponding to # 1 - 5 above for each type of monitoring you
are required to conduct.
Inactive and Unstaffed sites exception (if applicable)
If you are invoking the exception for inactive and unstaffed sites for benchmark monitoring, include information to
support this claim.
INSERT TEXT HERE
Substantially identical outfall exception (if applicable)
If you plan to use the substantially identical outfall exception for your benchmark monitoring and/or quarterly visual
assessment requirements, include the following information here to substantiate your claim that these outfalls are
substantially identical:
• Location of each of the substantially identical outfalls: INSERT TEXT HERE
• Description of the general industrial activities conducted in the drainage area of each outfall: INSERT TEXT
HERE
• Description of the control measures implemented in the drainage area of each outfall: INSERT TEXT HERE
• Description of the exposed materials located in the drainage area of each outfall that are likely to be
significant contributors of pollutants to stormwater discharges: INSERT TEXT HERE
• An estimate of the runoff coefficient of the drainage areas (low=under 40%; medium=40 to 65%; high
=above 65%): INSERT TEXT HERE
• Why the outfalls are expected to discharge substantially identical effluents: INSERT TEXT HERE
EPA Industrial SWPPP Template, January 13, 2009 14

Stonnwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
SECTION 5: INSPECTIONS
Instructions::
Describe.your procedures for performing the three types'of inspections required by the 2008 MSGP;
including:
■ Routine facility inspections (2008 MSGP, Part 4.1);
• Quarterly visual assessment of stormwater discharges (2008 MSGP, Part 4.2); and
■ Comprehensive site inspections (2008 MSGP, Part 4.3).
If you are invoicing the exception for inactive and unstaffed sites relating to routine facility inspections and
quarterly visual assessments, you must include in your SWPPP the information to support this claim as
required by 2008'MSGP, Parts 4:1.3 and 423.
— A sample routine facility inspection and quarterly visual assessment form is available on EPA's MSGP
website(www.epa.gov/npdes/stormwater/ms_qp) in the 'Additional MSGP Documentation" file. Appendix I of
the-2008 MSGP includes a comprehensive site inspection form (Annual Reporting Form).
For the routine facility inspections and the comprehensive site inspections to be performed at your site, include a
description of the following:
The names of the person(s), or the positions of the person(s), responsible for inspection: INSERT TEXT
HERE
The schedules to be used for conducting inspections. Include here any tentative schedule that will be used
for facilities in climates with irregular stormwater runoff discharges (2008 MSGP, Part 4.2.3): INSERT TEXT
HERE and
Specific areas of the facility to be inspected, including schedules for specific outfalls INSERT TEXT HERE
For the quarterly visual assessments to be performed at your site, include a description of the following:
■ The names of the person(s), or the positions of the person(s), responsible for inspection. INSERT TEXT
HERE
■ The schedules to be used for conducting inspections. Include here any tentative schedule that will be used
for facilities in climates with irregular stormwater runoff discharges (2008 MSGP, Part 4.2.3): INSERT TEXT
MERE and
■ Specific areas of the facility to be inspected, including schedules for specific outfalls: INSERT TEXT HERE
Inactive and Unstaffed sites exception (if applicable)
If you are invoking the exception for inactive and unstaffed sites for your routine facility inspections and quarterly
visual assessments, include information to support this claim.
INSERT TEXT HERE
EPA Industrial SWPPP Template, January 13, 2009 15

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
SECTION 6: DOCUMENTATION TO SUPPORT ELIGIBILITY
CONSIDERATIONS UNDER OTHER FEDERAL LAWS
6.1 Documentation Regarding Endangered Species.
Instructions (see 2008 MSGP Part 5.1.6.1):
Include any documentation you have that supports your determination of eligibility consistent with 2008 MSGP,
Part 1.1.4.5 (Endangered and Threatened Species and Critical Habitat Protection). Refer to Appendix E of the
2008 MSGP for specific instructions for establishing eligibility.
INSERT TEXT HERE OR KEEP DOCUMENTATION WITH SWPPP.
6.2 Documentation Regarding Historic Properties
Instructions (see 2008 MSGP Part 5.1.6.2):
Include any documentation you have that supports your_ determination of eligibility,. consistent with 2008 MSGP,
Part 1.1 A.6 (Historic Properties Preservation). Refer to Appendix F of the 2008 MSGP for specific instructions for
establishing. eligibility. "
INSERT TEXT HERE OR KEEP DOCUMENTATION WITH SWPPP.
6.3 Documentation Regarding NEPA Review (if applicable)
Instructions (see 2008 MSGP Part 5.1.6.3):
Include any documentation you have that supports your determination of eligibility consistent with MSGP 2008
Part 1.1.2.5 (Discharges Subject to Any New Source Performance Standards).
INSERT TEXT HERE OR KEEP DOCUMENTATION WITH SWPPP.
SECTION l: SWPPP CERTIFICATION
Instructions (see 2008 MSGP Part 5.1.7): _
The following certification statement must be signed and.dated by. aperson who meets the requirements of
Appendix B, Subsection 11.A or,11.8, of the 2008 MSGP. Note:. This cer6_fcatiori must be re -signed in the event
of a SWPPP modification in,response to a Part 3.1,trigger for corrective action.
EPA Industrial SWPPP Template, January 13, 2009 16

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
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.
Name:
Signature:
Title:
Date:
EPA Industrial SWPPP Template, January 13, 2009 17

Stormwater Pollution Prevention Plan (SWPPP)
INSERT FACILITY NAME and DATE
SECTION 8: SWPPP MODIFICATIONS
Instructions (see 2008 MSGP Part 5.2):
— Your SWPPP is a "living" document and is required to be modified and updated, as necessary, in response
to corrective actions. See Part 3.4 of the 2008 MSGP.
o If you need to modify the SWPPP inresponse to a corrective action required by Part 3. 1 of the 2008
MSGP, then the certification statement in section 7 of this SWPPP template must be re -signed in
accordance with 2008 MSGP Appendix B, Subsection 11.A or 11.B.
o For any other SWPPP modification, you should keep a log with a description of the modification, the
name of the person making it, and the date and signature of that person. See 2008 MSGP
Appendix B, Subsection 11.C.
INSERT LOG HERE or REFERENCE ATTACHMENT
EPA Industrial SWPPP Template, January 13, 2009 18

Stormwater Pollution Prevention Plan (SWPPP)
WSERT FACILITY NAME and DATE
SWPPP ATTACHMENTS
Attach the following documentation to the SWPPP:
Attachment A - General Location Map
Include a copy of your general location map in Attachment A.
Attachment B - Site Map
Include a copy of your site map(s) in Attachment B.
Attachment C - 2008 MSGP
Note: it is helpful to keep a printed -out copy of the 2008 MSGP so that it is accessible to you for
easy reference. However, you do not need to formally incorporate the entire 2008 MSGP into your
SWPPP. As an alternative, you can include a reference to the permit and where it is kept at the
site.
EPA Industrial SWPPP Template, January 13, 2009 19

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
V Q Additional MSGP Documentation Template
Introduction
ti n
After you become permitted under the 2008 MSGP, you are required to keep certain minimum
records (or documentation) as part of the Implementation of your permit responsibilities. As
required in Part 5.4 of the 2008 MSGP, these records must be kept in the same place your SWPPP
(which you completed prior to submitting your NOI to be covered) is kept. This "Additional MSGP
Documentation Template" (or "Template") will assist you in complying with this requirement.
Using the Additional MSGP Documentation Template
Tips for using the Template:
This Template is designed for use by all facilities permitted under the 2008 MSGP.
The Template is NOT tailored to your individual industrial sector. Depending on
which industrial sector(s) you fall under (see Appendix D of the 2008 MSGP) and
where your facility is located (see Appendix C of the 2008 MSGP), you will need to
address any additional documentation requirements outlined in Part 8 and/or Part
9 of the permit, respectively.
• Each section of the template includes "instructions" and space for your facility's
specific information. You should read the instructions before you complete each
section. The text you will need to complete is generally indicated through the use
of blue form fields (e.g., "Insert Facility Name"). Click on the form field and your
text will replace the instructional text.
• The Template was developed in Microsoft Word so that you can easily add tables
and additional text.
• Because many of the activities you are required to document occur throughout
the permit term, you will need to continually modify and add records to this
Template. You may wish to create separate electronic files for each category of
documentation (e.g., files for monitoring, employee training, etc.) so that they can
be easily modified.
• The records you create using this Template must be kept in the same location as
your SWPPP.
EPA notes that while EPA has made every effort to ensure the accuracy of all instructions and
guidance contained in the Template, the actual obligations of regulated industrial facilities are
determined by the relevant provisions of the permit, not by the Template. In the event of a conflict
between the Template and any corresponding provision of the MSGP, the permit provisions
establish your actual requirements. EPA welcomes comments on the Template at any time and
will consider those comments in any future revision of this document.
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
Additional MSGP Documentation
For:
Insert Facility Name
Insert Facility Address
Insert City, State, Zip Code
Insert Facility Telephone Number (if applicable)
Insert Facility Permit Tracking Number
Instructions:
'.Keep the following inspection, monitoring, and certification records in the"same [ovation that you keep your.
SWPPP '
A copy af.the NO1 submitted'to EPA along with any correspondence:exchanged bet+nieen=you and
EI?Aspecific,to coverage`untler this:permit(you,should.already�have this);-
• A copy of the acknouvledgmerit lettef you received from the NQ! Processing Center or eNQI `system
- assigning your permit tracking number,(you should already;have this);:.-
' -A copy:of 2008.'MSGP`(you'i an provide an electroniccopy).
• Descriptions and dates of ahy incidences of significant spills, leaks; orother.-releases
-Records of employee training;, , -
bocumentation.of maintenance and`repairs of.controi measures,
• All inspection reports, t {
_Description of'any deviations from the schedule for visual assessments and/or monitonng, �F
, . .
• Description of any corrective action taken at your site;, £
Documentation of any benchmark ezceedances.and how they were:responded to; ,
• Qocumentationao stipport any determination that pollutants of. concern are not. expected to tie,
present above:natural background levels, and that such pollutants were not detectedaln your"
h dlschargev were solely.'attntiutatile`to natural'background sources; and `� r
• .bocumei�tation to support your cEaim`that your:faeility__h cha dedrits status_from active tdJhactive ••
and unstaffed. _ M ti = :. : �. ',
of eyhA . �.' ' 1 LLh
:With the exception of the first 3 items, these are records that you will be updating throughout the permit,
`term P �i1 Y r t h
-the instructions in'Sections A through iUl of this template to keep your records complete
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSG Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
Contents
A. Significant spills, leaks or other releases ......................
B. Employee training..............................................................................................................
2
C. Maintenance......................................................................................................................
3
D. Routine Facility Inspection Reports......................................................................................
5
E. Quarterly Visual Assessment Reports ............................. ...........
10
F. Comprehensive Site Inspection Reports.............................................................................
12
G. Monitoring results............................................................................................................
13
H. Deviations from assessment or monitoring schedule...........................................................
14
1. Benchmark Exceedances...................................................................................................
15
J. Impaired Waters Monitoring: Documentation of Natural Background Sources or Non -Presence
ofImpairment Pollutant.........................................................................................................
16
........................................
K. Active/Inactive status change .................................................. ..
17
L. SWPPP Amendment Log..................................................................................................
18
M. Miscellaneous Documentation..........................................................................................
19
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
A. Significant spills, leaks or other releases
Instructions: .
Include the descriptions and dates of any incidences of significant spills, leaks, or other releasesthat
resulted in discharges of pollutants to _waters of the U.S., through stomnwateror otherwise; -the
circumstances leading to the release and actions taken in response to the release; and measures taken to
prevent the recurrence of such releases (see Part 2.9.2.4 of,Tthe 2008 MSGP).
Provide information, as shown below, for each incident, and attach additional documentation (e.g., photos,
spill cleanup records) as necessary. Repeat as necessary by copying and pasting the fields below. .
Date of incident: Insert Date of Incident
Location of incident: Insert Location of Incident
Description of incident: Insert Description of Incident
Circumstances leading to release: Describe circumstances leading to release
Actions taken in response to release: Describe actions taken in response to release
Measures taken to prevent recurrence: Describe measures taken to prevent recurrence
Date of incident: Insert Date of Incident
Location of incident: Insert Location of Incident
Description of incident: Insert Description of Incident
Circumstances leading to release: Describe circumstances leading to release
Actions taken in response to release: Describe actions taken in response to release
Measures taken to prevent recurrence: Describe measures taken to prevent recurrence
Date of incident: Insert Date of Incident
Location of incident: Insert Location of Incident
Description of incident: Insert Description of incident
Circumstances leading to release: Describe circumstances leading to release
Actions taken in response to release: Describe actions taken in response to release
Measures taken to prevent recurrence: Describe measures taken to prevent recurrence
Date of incident: Insert Date of Incident
Location of incident: Insert Location of Incident
Description of incident: Insert Description of Incident
Circumstances leading to release: Describe circumstances leading to release
Actions taken in response to release: Describe actions taken in response to release
Measures taken to prevent recurrence: Describe measures taken to prevent recurrence
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERM]T TRACKING NUMBER
B. Employee training
Instructions:
— Keep records of employee training, including the date of the training (see Part 2.1.2.9 of the 2008.MSGP).
— For in -person training, consider using the tables below to document your employee trainings. For
computer -based or other types of training, keep similar records on who was trained and the type of training
conducted.
Training Date: Insert Date of Training
Trainin Description; Insert Description of Training
Trainer: Insert Trainers names
Employee(s) trained
Employee signature_
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
Training Date: Insert Date of Training
Training Description- Insert Description of Training
Trainer: Insert Trainers names
Employee(s) trained
Employee signature
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
Training Date: Insert Date of Training
Training Description: Insert Description of Training
Trainer: Insert Trainer(s) names
Employee(s) trained
Employee signature
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
Insert Name
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
C. Maintenance
Instructions:
— Include in your.records documentation of maintenance and repairs of control measures and industrial
equipment, including:
the control measure/equipment maintained,
date(s) of regular maintenance,VN
- date(s) of discovery of areas in -need of repair/replacement, and for repairs',
date(s) that the control measure/equipment was returned to full function, and
- the justification for any extended main ten ancelrepair schedules (see Part 2.1.2.3 of the
2008 MSGP).
— Provide information, as shown below, to document your maintenance activities for each control measure
and industrial equipment. Repeatas necessary by copying and pasting the information below for
additional control measures. .
Control Measure Maintenance Records (copy information below for each control measure)
Control Measure: Insert Name of Control Measure
Regular Maintenance Activities: Describe maintenance activities
Regular Maintenance Schedule: Insert Maintenance Schedule
Date of Action: Insert Date of Action
Reason for Action: ❑ Regular Maintenance ❑ Discovery of Problem
If Problem,
• Description of Action Required: Describe actions taken in response to problem
• Date Control Measure Returned to Full Function: Insert Date
• Justification for Extended Schedule, if applicable: Insert Justification (if applicable)
Notes: Insert Notes (if applicable)
EPA Additional MSGP Documentation Template, January 13, 2009

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
Industrial Equipment and Systems Maintenance Records (copy information below for each
industrial equipment/system)
Industrial EquipmentlSystems: Insert Name of Industrial Equipment/System
Regular Maintenance Activities: Describe maintenance activities
Regular Maintenance Schedule: Insert Maintenance Schedule
Date of Action: Insert Date of Action
Reason for Action: ❑ Regular Maintenance ❑ Discovery of Problem
If Problem,
- Description of Action Required: Describe actions taken in response to problem
- Date Industrial Equipment Returned to Full Function: Insert Date
- Justification for Extended Schedule, if applicable: Insert Justification (if applicable)
Notes: Insert Notes (if applicable)
EPA Additional MSGP Documentation Template, January 13, 2009 4

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
D. Routine Facility Inspection Reports
Instructions:
— Include in your records copies of all routine facility inspection reports completed for the facility.
The sample inspection report is consistent with the requirements in Parts 4.1 of the 2008 MSGP relating to
routine facility inspections. Facilities subject to State industrial stormwater permits may also find this form
useful. If your permitting authority provides you with=an, inspection report, use that form.
Using the Sample Routine Facility Inspection Report
This inspection report is designed to be customized according to the specific control measures and
activities at your facility. For ease of use, you should take a copy of your site plan and number all of the
stormwater control measures and areas of industrial activity that will be inspected:. A brief description of
the control measures and areas that were inspected should then be listed in the site -specific section of the
inspection report.
You can complete the items in the "General Information" section that will remain constant, such as the
facility name, NPIDES tracking number, and inspector (if you only use one inspector). Print out multiple
copies of this customized inspection report to use during your inspections.,
- When conducting the inspection, walk the site by following_ your site. map and numbered control
measures/areas of industrial activity to be inspected. Also note whether the:"Areas_ of Industrial Materials_
or Activities exposed to stormwate ( have been addressed customize this list according to the conditions
:
at your facility). Note any required corrective actions and the date and responsible person for the
correction.
EPA Additional MSGP Documentation Template, January 13, 2009

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
I Insert StarUEnd 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 SWPPP
Weather Information
Weather at time of this inspection?
❑ Clear ❑Cloudy ❑ Rain
❑ Other:
❑ Sleet ❑ Fog ❑ Snow ❑ High Winds
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.
• Describe corrective actions initiated, date completed, and note the person that completed the work in the Corrective Action
Log.
Structural Control
Control
If No, In Need of
Corrective Action Needed and Notes
Measure
Measure is
Maintenance,
(identify needed maintenance and repairs, or any
Operating
Repair, or
failed control measures that need replacement)
Effectively? ?
Replacement?
I
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
© Repair
❑ Replacement
Z
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
3
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
4
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
5
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
6
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
7
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
8
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement

Structural Control
Control
if No, In Need of
Corrective Action Needed and Notes
Measure .
Measure is
Maintenance,
(identify needed maintenance and repairs, or any
Operating
:Repair, or
failed control measures that need replacement)
Effectively?
Replacement?
9
Insert Control Measure
QYes ❑No
Cl Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
10
Insert Control Measure
❑Yes ❑No
❑ Maintenance
Describe Corrective Actions
Name
❑ Repair
❑ Replacement
Areas of Industrial Materials or Activities exposed to stormwater
.below are some general areas that should be assessed during routine inspections. Customize this list as needed for the specific
types of industrial materials or activities at your facility.
Area/Activity
Inspected.?
Controls
Corrective Action Needed and Notes
Adequate
(appropriate,
effective, and
o eratin ?
i
Material
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
loading/unloading and
storage areas
2
Equipment operations
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
and maintenance areas
3
Fueling areas
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
4
Outdoor vehicle and
❑Yes ❑No 0 N/A
❑Yes ❑No
Describe Corrective Actions
equipment washing areas
5
Waste handling and
:]Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
disposal areas
6
Erodible
❑Yes ONo ❑ N/A
❑Yes ONo
Describe Corrective Actions
areas/construction
7
Non-stormwater/ illicit
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
connections
8
Salt storage piles or pile
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
containing salt
9
Dust generation and
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
vehicle tracking
10
(Other)
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
11
(Other)
❑Yes ❑No ❑ NIA
❑Yes ❑No
Describe Corrective Actions
12
(Other)
❑Yes ❑No ❑ N/A
❑Yes ❑No
Describe Corrective Actions
Non -Compliance

Additional Control Measures
Notes
Use this space for any additional notes or observations from the inspection:
Additional Notes
CERTIFICATION STATEMENT
"1 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.
1 am aware that there are significant penalties for submitting false information, including the possibility of fine and
imprisonment for knowing violations."
Print name and title:
Signatu re: Date:

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
E. Quarterly Visual Assessment Reports
Instructions:
Include in your records copies of all quarterly visual _assessment reports completed for the facility. An
example quarterly visual assessment report can be found on the -following page.
EPA Additional MSGP Documentation Template, January 13, 2009 10

MSGP Quarterly Visual Assessment Form
(Complete a separate form for each outfall you assess)
Name of Facility: Name of Facility NPDES Tracking No, Insert Tracking No.
Outfall Name: Name "Substantially identical Outfall"? ❑ No ❑ Yes (identify substantially identical outfalls):
Person(s)rfitle(s) collecting sample: Name/Title
Person(s)ITitle(s) examining sample: Name/Tide
Date & Time Discharge Began: Date & Time Sample Collected: Date & Time Sample Examined:
Enter date and time Enter date and time Enter date and time
Substitute Sample? ❑ No ❑ Yes (identify quarter/year when sample was originally scheduled to be collected):
Nature of Discharge: ❑ Rainfall ❑ Snowmelt
If rainfall: Rainfall Amount: No of Previous Storm Ended > 72 hours ❑ Yes ❑ No' (explain):
inches inches Before Start of This Storm?
Parameter
Color ❑ None ❑ Other (describe):
Odor ❑ None ❑ Musty ❑ Sewage ❑ Sulfur ❑ Sour ❑ Petroleum/Gas
❑ Solvents ❑ Other (describe):
Clarity ❑ Clear ❑ Slightly Cloudy ❑ Cloudy ❑ Opaque ❑ Other
Floating Solids ❑ No ❑ Yes (describe):
Settled Solids" ❑ No ❑ Yes (describe):
Suspended Solids ❑ No ❑ Yes (describe):
Foam (gently shake sample) ❑ No ❑ Yes (describe):
Oil Sheen ❑ None ❑ Flecks ❑ Globs ❑ Sheen ❑ Slick
❑ Other (describe):
Other Obvious Indicators ❑ No ❑ Yes (describe):
of Stormwater Pollution
The 72-hour interval can be waived when the previous storm did not yield a measurable discharge or if you are able to document (attach applicable document
that less than a 72-hour interval is representative of local storm events during the sampling period.
" Observe for settled solids after allowing the sample to sit for approximately one-half hour.
Detail any concerns, additional comments, descriptions of pictures taken, and any corrective actions taken below (attach additional
sheets as necessary). Insert details
Certification by Facility Responsible Official (Refer to MSGP Subpart 11 Appendix B for Signatory Requirements)
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 a
that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or tl
persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I ai
aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
A. Name: B. Title:
C. Signature: D. Date Signed:

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
F. Comprehensive Site Inspection Reports
Instructions:
Include in your records copies of all comprehensive site inspection reports completed for the facitity.
Copies of the comprehensive site inspection report form'(also called the Annual Reporting Form) can be
obtained at http:llwww.ppa_:gov/npdes/pubs/msgp2008 appendixi.pdf
— 'For corrective actions, complete part D (Corrective Actions) of the Annual Reporting Form.
EPA Additional MSGP Documentation Template, January 13, 2009 12

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACII i"TY PERMIT TRACKING NUMI3ER
G. Monitoring results
Instructions:
Include in your records copies of all monitoring results (including benchmarks, effluent limits, and other
monitoring conducted) for the facility. Also include copies of MSGP Industrial Discharge Monitoring
Reports (DMRs) submitted to EPA, or copies of monitoring data submitted to EPA's eNO1 reporting
system.
EPA Additional MSGP Documentation Template, January 13, 2009 13

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PI-RMIT TRACKING NUMBER
H. Deviations from assessment or monitoring schedule
Instructions:
Include in your records:
A description of any deviations from the schedule,you provided in,yourSWPPP for visual assessments
and/or monitoring, and
The reason for the deviations (e.g., adverse weather or it was impracticable to collect samples within the
first 30 minutes of a measurable storm event) (see Parts 4.2.1, 6.1.4, and 6.2.1.2 of the`2008 MSGP).
Use the fields below to document the deviations. Repeat as necessary for any deviations.
Date: Insert Date
❑ Visual assessments ❑ Monitoring
Describe deviation from schedule: Describe deviation
Reason for deviation: Describe reason
Date: Insert Date
❑ Visual assessments ❑ Monitoring
Describe deviation from schedule: Describe deviation
Reason for deviation: Describe reason
Date: Insert Date
❑ Visual assessments ❑ Monitoring
Describe deviation from schedule: Describe deviation
Reason for deviation: Describe reason
Date: Insert Date
❑ Visual assessments ❑ Monitoring
Describe deviation from schedule: Describe deviation
Reason for deviation: Describe reason
EPA Additional MSGP Documentation Template, January 13, 2009 14

Additional MSGP Documentation
INSERT 1ACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
I. Benchmark Exceedances
Instructions:
Include in your records documentation of any benchmark exceedances and how they were responded to,
including either:
— (1) corrective action taken,
— (2) a finding that the exceedence was due to natural background pollutant levels, or
(3) a finding that no further pollutant reductions were technologically available and economically
practicable and achievable in light of best industry practice consistent with Part 6.2.1.2 of the 2008 MSGP.
Date: Insert Date
Parameter Exceeded and Results: Insert Parameter 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 2008 MSGP
Document how benchmark exceedance(s) responded to:
❑ Corrective action taken
Parameter(s): Insert Parameter
Complete Part D (corrective actions) of the Annual Report Form (see section F of the
Additional MSGP Documentation).
❑ Finding that the exceedence was due to natural background pollutant levels
Parameter(s): Insert Parameter
Attach the following documentation:
• An explanation of why you believe that the presence of the pollutant causing the
impairment in your discharge is not related to the activities at your facility; and
• Data and/or studies that tie the presence of the pollutant causing the impairment in
your discharge to natural background sources in the watershed.
❑ Finding that no further pollutant reductions are technologically available and
economically practicable and achievable in light of best industry practice consistent with
Part 6.2.1.2.
Parameter(s): Insert Parameter
Attach documentation.
EPA Additional MSGP Documentation Template, January 13, 2009 15

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMI3ER
J. Impaired Waters Monitoring: Documentation of Natural
Background Sources or Non -Presence of Impairment Pollutant
Instructions:
This section applies only if your facility:
• , Discharges directly to -an impaired water without an EPA approved or established total
maximum daily load (TMDL), and either your impaired waters monitoring results shows that the
pollutant(s) for which the water is impaired is
1. Not present and not expected to be present in your discharge, or
2. Present, but you have determined its presence is caused solely by natural
background sources. See Part.6.2.4.2 of the 2008 MSGP. ;
If ,# 1 applies to your facility, include here documentation that the impairment pollutant(s) was not' "
detected in your discharge sample.
If # 2 applies to your facility, include the following documentation here:
• An explanation of why you believe that the presence of the pollutant(s) causing 'the impairment
in your discharge is not related to the activities at your facility; and
• Data and/or studies that tie the presence of the pollutant(s)'causing the impairment in your
discharge to natural background sources in the watershed.
Note: You are reminded that the permit requires you to include a notification that you have met either
condition # 1 or # 2 (above) in your monitoring report that you submit to EPA.
Date: Insert Date
Check one of the boxes below and complete the additional documentation:
❑ #1 — Pollutant(s) for which the water is impaired is not present and not expected to be
present in your discharge
Attach documentation that the impairment pollutant(s) was not detected in your discharge
sample(s).
❑ #2 — Pollutant(s) for which the water is impaired is present, but you have determined its
presence is caused solely by natural background sources.
Attach the following documentation:
• An explanation of why you believe that the presence of the pollutant(s) causing the
impairment in your discharge is not related to the activities at your facility; and
• Data and/or studies that tie the presence of the pollutant(s) causing the impairment in your
discharge to natural background sources in the watershed.
EPA Additional MSGP Documentation Template, January 13, 2009 16

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
K. Active/inactive status change
Instructions:
If your facility changes it status from active to inactive and unstaffed (or from inactivelunstaffed to active), include
documentation in this section to support your claim.
Date: Insert Date of Change in Status
New Facility Status: ❑ Inactive and Unstaffed ❑ Active,
Reason for change in status: Describe reason
EPA Additional MSGP Documentation Template, January 13, 2009 17

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
L. SWPPP Amendment Log
Instructions:.
Include in your:records: wr
X
= A log of the date and description of any amendments to your SWPPP.
Fill in the appropriate columns of this. table for each amendment to your SWPPP. Copy and_paste additional .rows
into the table as necessary.
Amend
Di3scriptjonfof'the'Amen�meint
105t-516!
AmendmentlPreparedent by [Name{sj and Title]
1
Insert description of amendment
Insert date
Insert nameltitle
2
Insert description of amendment
Insert date
Insert nameltitle
3
Insert description of amendment
Insert date
Insert nameltitle
4
Insert description of amendment
Insert date
Insert nameltitle
5
Insert description of amendment
Insert date
Insert nameltitle
6
Insert description of amendment
Insert date
Insert nameltitle
7
Insert description of amendment
Insert date
Insert nameltitle
8
Insert description of amendment
Insert date
Insert nameltitle
9
Insert description of amendment
Insert date
Insert nameltitle
10
Insert description of amendment
Insert date
Insert nameltitle
11
Insert description of amendment
Insert date
Insert nameltitle
EPA Additional MSGP Documentation Template, January 13, 2009 18

Additional MSGP Documentation
INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER
M. Miscellaneous Documentation
Instructions:
Use this section to keep records of any additional documentation that relates to your compliance with the permit.
EPA Additional MSGP Documentation Template, January 13, 2009 19