Annual Reporting Form - Environmental Protection Agency
NPDES Permit Tracking No.:
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
Annual Reporting Form
A. GENERAL INFORMATION
1. Facility Name:
2. NPDES Permit Tracking No.:
3. Facility Physical Address:
a. Street:
b. City:
c. State:
d. Zip Code:
-
4. Lead Inspectors Name:
Title:
Additional Inspectors Name(s):
5. Contact Person:
Title:
Phone:
- -
Ext.
E-mail:
6. Inspection Date:
/ /
B. GENERAL INSPECTION FINDINGS
1. As part of this comprehensive site inspection, did you inspect all potential pollutant sources, including areas where industrial activity may be exposed to stormwater?
YES NO
If NO, describe why not:
NOTE: Complete Section C of this form for each industrial activity area inspected and included in your SWPPP or as newly identified in B.2 or B.3 below where pollutants
may be exposed to stormwater.
2. Did this inspection identify any stormwater or non-stormwater outfalls not previously identified in your SWPPP? YES NO
If YES, for each location, describe the sources of those stormwater and non-stormwater discharges and any associated control measures in place:
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