20170239 Ver 2_NPDES - 12.14.20 thru 12.20.20_20210506

04/2019 SPPPFORM30
INSPECTION RECORD FOR ACTIVITIES UNDER STORMWATER GENERAL PERMIT NCGO10000
SELF-INSPECTION RECORD FOR LAND DISTURBING ACTIVITIES PER§ 113A-54.1
RESPONSE FOR EROSION CONTROL FORM 1675
PROJECT LOCATION TIP/WBS#
LEVEL II SUPERVISOR COUNTY
CONTRACTOR
All erosion and sedimentation control measures and stormwater discharge outfalls must be inspected once per seven calendar days AND
within 24 hours of a rainfall of 1.0 inch or greater per 24-hour period. Permittee must keep a record of inspections. If using on site rain
gage, complete daily rainfall measurement. If using Multi Precipitation Estimator(MPE), attach rainfall data for weekly period.
Day Date Rain Notes Exceptions to standard monitoring requirements
FAimt in
000 Idle projects: Idle projects must be inspected once every 14
TT calendar days and after 1.0" of rain in a 24-hour period. Idle
W projects are projects that have not been completed but where no
Th construction activity occurs for 21 calendar days or more AND
F the entire project has been adequately stabilized with temporary
Sat vegetation pursuant to DEMLR guidelines.
Sun 00 Completed projects: Completed projects are those projects
where work has been completed and you're waiting for the
Phase of Grading permanent vegetation to establish (i.e. waiting for the grass to
Place a check in the box of the current projectphase) grow). Completed projects must be inspected once every 30
Installation of perimeter erosion and sediment control measures calendar days AND within 24 hours of a rain event 1.0 inch or
Clearing and grubbing of existing ground cover greater in 24 hours. The reduced monitoring can begin once
Completion of any phase of grading of slopes or fills construction has been completed,and erodible slopes have been
Installation of storm drainage facilities sufficiently stabilized to restrain erosion by application of
Completion of construction or development permanent ground cover varieties and installation of temporary
Establishment of permanent ground cover sufficient to restrain erosion ground cover to include appropriate erosion control matting
and/or other approved mulch materials.
Has all land disturbing activity been completed?(Y/N)
Has the final permanent ground cover been completed and established?(Y/N)
By this signature,I certify(in accordance with Part IV,Section B,6(d)of the NCGO10000 permit)
that this report is accurate and complete to the best of my knowledge: Form should not be signed until the week is complete and ALL
corrective actions have been completed in the 24 hour and/or 5
day time periods.
Cert.Level II Supervisor Cert. #
NCDOT Cert.Level II Representative Cert.#

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO) Visible Sedimentation and Stream
(Required to list each SDO for each inspection) Turbidity
Inspection Station Number Corrective Actions Needed Priority* Date other Sediment Stream
Date Corrected Pollutants** Deposited*** Clarity****
*R=Routine,needs **Is there evidence of other pollutants discharging from ***Is there visible sediment deposited in a stream, ****Is there visible
attention within 5 site such as oil sheen,discoloration,cement wastes, wetland,buffer or adjacent property?(Y/N)Contact decrease in stream clarity
days;U=Urgent, sanitary waste,fertilizers,or fuel or chemical storage DWR within 24 hours if visible sediment greater than a 5 (increase turbidity-cloudy)
needs attention leakage?(Y/N)**If Other Pollutants is marked Yes, gallon bucket is deposited in surface waters or wetlands, because of a discharge?
within 24 hrs. describe extent of discharge and list the corrective actions and DEMLR if greater than 5 gallon bucket lost off site. (Y/N)
taken.Report potential illicit discharges to NCDOT for
confirmation/reporting.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as"URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO) Visible Sedimentation and Stream
(Required to list each SDO for each inspection) Turbidity
Inspection Station Number Corrective Actions Needed Priority* Date other Sediment Stream
Date Corrected Pollutants** Deposited*** Clarity****
*R=Routine,needs **Is there evidence of other pollutants discharging from ***Is there visible sediment deposited in a stream, ****Is there visible
attention within 5 site such as oil sheen,discoloration,cement wastes, wetland,buffer or adjacent property?(Y/N)Contact decrease in stream clarity
days;U=Urgent, sanitary waste,fertilizers,or fuel or chemical storage DWR within 24 hours if visible sediment greater than a 5 (increase turbidity-cloudy)
needs attention leakage?(Y/N)**If Other Pollutants is marked Yes, gallon bucket is deposited in surface waters or wetlands, because of a discharge?
within 24 hrs. describe extent of discharge and list the corrective actions and DEMLR if greater than 5 gallon bucket lost off site. (Y/N)
taken.Report potential illicit discharges to NCDOT for
confirmation/reporting.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as"URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO) Visible Sedimentation and Stream
(Required to list each SDO for each inspection) Turbidity
Inspection Station Number Corrective Actions Needed Priority* Date other Sediment Stream
Date Corrected Pollutants** Deposited*** Clarity****
*R=Routine,needs **Is there evidence of other pollutants discharging from ***Is there visible sediment deposited in a stream, ****Is there visible
attention within 5 site such as oil sheen,discoloration,cement wastes, wetland,buffer or adjacent property?(Y/N)Contact decrease in stream clarity
days;U=Urgent, sanitary waste,fertilizers,or fuel or chemical storage DWR within 24 hours if visible sediment greater than a 5 (increase turbidity-cloudy)
needs attention leakage?(Y/N)**If Other Pollutants is marked Yes, gallon bucket is deposited in surface waters or wetlands, because of a discharge?
within 24 hrs. describe extent of discharge and list the corrective actions and DEMLR if greater than 5 gallon bucket lost off site. (Y/N)
taken.Report potential illicit discharges to NCDOT for
confirmation/reporting.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as"URGENT".

04/2019 SPPPFORM30
Stormwater Discharge Outfalls (SDO) Visible Sedimentation and Stream
(Required to list each SDO for each inspection) Turbidity
Inspection Station Number Corrective Actions Needed Priority* Date other Sediment Stream
Date Corrected Pollutants** Deposited*** Clarity****
*R=Routine,needs **Is there evidence of other pollutants discharging from ***Is there visible sediment deposited in a stream, ****Is there visible
attention within 5 site such as oil sheen,discoloration,cement wastes, wetland,buffer or adjacent property?(Y/N)Contact decrease in stream clarity
days;U=Urgent, sanitary waste,fertilizers,or fuel or chemical storage DWR within 24 hours if visible sediment greater than a 5 (increase turbidity-cloudy)
needs attention leakage?(Y/N)**If Other Pollutants is marked Yes, gallon bucket is deposited in surface waters or wetlands, because of a discharge?
within 24 hrs. describe extent of discharge and list the corrective actions and DEMLR if greater than 5 gallon bucket lost off site. (Y/N)
taken.Report potential illicit discharges to NCDOT for
confirmation/reporting.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as"URGENT".

04/2019 SPPPFORM30
Erosion & Sedimentation Control Devices
(Required to list all devices that need maintenance)
Inspection Station Number Corrective Actions Needed Priority* Date
Date Corrected
*R=Routine,needs attention within 5 days;U=Ur ent,needs attention within 24 hours.
NOTE: Any erosion control device that is damaged that has the potential to lose sediment and/or pollutants offsite and/or into surface waters should be treated as"URGENT".

04/2019 SPPPFORM30
RESPONSE FOR EROSION CONTROL-INSPECTOR'S DAILY REPORT
SUBSTITUE FORM 1675
Pay Item Standard/Metric Unit Quantity Comments
Temporary Silt Fence LF M
Special Sediment Control Fence TN/MTN LF/M
Temporary Mulching AC HA
Seed-Temporary Seeding LB KG
Fertilizer-Temporary Seeding TN MTN
Matting for Erosion Control SY M2
Coir Fiber Mat SY M2
Coir Fiber Baffles LF M
Perm. Soil Reinforcement Mat SY M2
Seeding and Mulching AC HA
Seed-Repair Seeding LB KG
Fertilizer-Repair Seeding TN MTN
Seed for Supplemental Seeding LB KG
Fertilizer Topdressing TN MTN
Response for Erosion Control EA EA
Safety/Highly Visible Fencing LF M
We agree that this is the work to be performed. We agree that this work was performed.
NCDOT Representative: NCDOT Representative:
Prime Representative: Prime Representative:
Date Date