Item #23 - CoWS Industrial & MGH Form Template docx

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Stormwater/Erosion Control Division
Industrial and Municipal Good Housekeeping Inspection Form
General Information
A) Official Company Name:
B) Physical Address:
C) Telephone Number:
D) Mailing Address, if different from above address:
E) Authorized contacts to represent entity in environmental regulatory issues:
Primary contact:
Title:
Contact number(s):
Email address:
Secondary contact:
Title:
Contact number(s):
Email address:
F) Standard Industrial Classification (SIC) Number of business/operation (if applicable):
G) NC Stormwater NPDES Permit Number (if applicable):
Permit Category:
H) Any other control authority permit(s) (e.g. air quality control, wastewater, hazardous waste) & number(s):
I) Brief description of facility activities that occur on -site:
I) Ultimate Receiving Waters:
TMDL stream ❑Yes ❑No If Yes, What Pollutants:
Part 1 - Stormwater Controls
1. Best Management Practices (BMPs)
a. List the controls ( structural or non-structural) employed by the
E.g. Oil Water separators, cleaning schedules, structural BMP maintenance records
1.
2.
3.
4.
5.

b. Are the non-structural BMPs reasonable & appropriate for the facility? ❑Yes ❑No
Comments
c. Are stormwater control measures (SCMs) installed correctly, maintained, and effective operating condition?
❑Yes ❑ No ❑ N/A
2. Provide a brief description of other controls that manage/prevent/minimize stormwater runoff
(e.g., erosion and sediment controls, inlet protection/control at storm drains, diversion structures):
Part 2 — Stormwater Discharge Outfalls (SDOs)
1. Any evidence of discharge to receiving waters/1\4S4 from the SDOs? (e.g.: stormwater runoff, dry weather
discharge, co -mingling of process wastewater, trash, debris, oil and grease): ❑Yes ❑No
2) Do the stormwater outfalls on -site correspond with those listed on the site map in the Stormwater Pollution
Prevention Plan (SWPPP)? ❑Yes ❑No

3) Summary of Stormwater Discharge Outfalls
SDO Identification
Potential Pollutants that
could be discharged
Physical Location
Latitude and
Longitude
if known

Part 3 - BMP: Inspection and maintenance program
Yes N/A No Notes
Is secondary containment provided for materials (including
waste) or products stored outside in tanks and/or containers
where applicable)?
Are secondary containment free of accumulated water, debris,
cracks, holes, or evidence of leaks?
Does the facility maintain secondary containment drain logs?
Do the drain logs confirm the presence of pollutants and other
pertinent information, such as signatory requirements, name of
secondary containment area, date, time, and if drainage is
connected to MS4 or receiving waters?
Are tanks and containers in good condition, closed, and
properly marked?
Are tanks, containers, and piping free of rust, pits, deterioration,
or evidence of leaks?
Are tanks and containers protected from impacts from moving
vehicles and equipment? E.g. bollards and curbs
Any activities that have not been addressed or designed in order
to minimize exposure to runoff (e.g. herbicide application)
In the case of a spill, does the municipal operation or industrial
facility maintain and submit documentation to the City of WS
on a spill release form?
Any roof stacks that have the potential to release
solids/particulate?
Are all hazardous materials properly labeled and stored to
prevent exposure to stormwater runoff?
Are solid waste containers in good condition and of sufficient
size to contain all waste? If so, how is this determined?
Do the solid waste containers have covers and closed drain
plugs?
Are solid waste containers free of waste that requires special
handling/disposal? Are containers properly labeled to ensure
correct disposal means?
Are solid waste containers labeled "Prohibited - No Hazardous
Waste, No Recyclable Materials, No Liquids?"
Are special containers provided for other types of waste? E.g.
liquid waste or hazardous waste
Does the facility utilize oil water separators? If yes, are the
inspection and maintenance records documented?
Are secondary containment drain valves maintained in the
closed position, unless the facility is draining the secondary
containment?

Part 4 — Stormwater Pollution Prevention Plan (SWPP) Review
Site Overview
Yes No Notes
Is there a SWPPP? Is it up-to-date?
Does SWPPP include a certification statement by the responsible
corporate officer?
Does the general map depict the facility's location on a USGS quad
ma orequivalent ma with receiving waters or MS4 listed?
Identification of impaired waters or watershed (if applicable)?
Narrative Description of these Industrial/Operational Activities:
Storage Practices
Unloading/Loading Activities
Outdoor Processes
Particulate Generating/Control Processes
Waste Disposal
Vehicle/Equipment Washing
Does site map denote drainage items: flow direction, boundaries, %
impervious, and structures? Does the map also include SDOs,
industrial activity areas, and site topography?
A list of major spills that have occurred within the past three years
with corrective actions to prevent futurespills)?
A signed, annual certification that the facility has been tested for
non-stormwater discharges from the site?
Comments:

Stormwater Management Strategy
Yes No Notes
Does SWPPP incorporate the nine baseline controls:
Feasibility Study (technical & economic review to minimize pollutant exposure)
Secondary Containment (table summary of tanks, stored materials, release records)
BMP Summary (listing of site structural/nonstructural practices)
PM & GH (inspection of material handling areas & regular cleaning schedules)
Facility Inspections (biannual inspections of facility and all stormwater systems,
were the inspections completed during separate parts of the year?)
Employee Training (annual basis for staff who perform SPRP and GH functions)
Responsible Party (specific position(s)/person(s)-developing, implementing, &
revising SWPPP)
Amendment & Annual Update (of major spills, non-sw flows, BMPs, sampling data)
Does SWPPP contain completed routine inspection reports/records
regarding reportable implementation of the nine baseline controls
(e.g. SWPPP Implementation)?
Does the Spill Response Procedures (SPRP) document all spills and
releases? Does the entity properly dispose of contaminated materials
used in the clean up? Is the disposal of materials documented? Has a
contact person(s) and contact information been identified and
documented for each facility?
Analytical Monitoring (if not applicable, please notate)
Yes No Notes
Are samples collected within 30 minutes of the first discharge from
a measurable rain event and at least 72 hours since the last storm
event?
Are sampling events 60 days apart? (EXCEPTION: Tier 2 & 3 responses)
Is analytical monitoring complete (including schedule) for each
SDO? (EXCEPTION: REPRESENTATIVE OUTFALL STATUS)
Any exceedances of pollutant parameters when compared against
the permit benchmark values? If yes, have they documented their
response to the Department of Environmental Quality?
Has the facility implemented appropriate, selected actions to
reduce pollutant concentrations, in response to benchmark
exceedances (if applicable)?

Qualitative Monitoring
Yes No Notes
Is qualitative monitoring being performed during measurable storm
events?
Is qualitative monitoring complete (including schedule) for each
SDO?
Are monitoring events 60 days apart? (EXCEPTION: Tier 2 & 3 responses)
Any observable, excessive amounts of pollutant indicators in
stormwater discharge at SDOs?

Part 5 — Required Actions to be completed by Facility:

Part 6 —Action Items Completed that reduce pollutants:
How many action items were recommended that will reduce pollutants?
Entity Representative(s) that participated in inspection:
Title(s):
Start of Inspection:
Completion of Inspection:
Date:
Signature of Inspector:
Title: