ADEM Form 23 11-11 1 of 2
ADEM NPDES CONSTRUCTION STORMWATER INSPECTION REPORT AND BMP CERTIFICATION
RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH INCOMPLETE OR INCORRECT ANSWERS, OR MISSING SIGNATURES WILL BE RETURNED
AND MAY RESULT IN APPROPRIATE COMPLIANCE ACTION BY THE DEPARTMENT. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED
SHEET(S) AS NECESSARY. PLEASE TYPE OR PRINT IN INK
.
Item I.
Permittee Name: Facility/Site Name:
Permit Number:
County:
Facility Entrance Latitude & Longitude: Phone Number:
Facility Street Address or Location Description:
Item II.
List name of current ultimate receiving water(s) (indicate if through MS4) and the number of disturbed acres which drains through each
treatment system or BMP: Add additional sheet(s) if necessary.
Receiving Water Disturbed Acres Discharge Point # Representative Outfall
YES NO
YES NO
YES NO
YES NO
YES NO
Item III.
1. YES NO Did discharges of sediment or other pollutants occur from the site? If “Yes”, please list a description of the
discharge(s) and their location(s):
2. YES NO Were BMPs properly implemented and maintained at the time of inspection? If “No”, please provide location(s) and
descriptions of BMPs that need maintenance:
3. YES NO Are BMPs needed in addition to those already present onsite at the time of inspection? If “Yes” please provide a
description and location of additional BMPs that are needed:
4. YES NO Have any BMPs failed to operate as designed? If “Yes”, please provide location(s) and description of BMP(s) that
failed:
5. YES NO Were there BMPs required by the CBMPP that were not installed or installed in a manner not consistent with the
CBMPP? If “Yes”, please provide a description and location where the BMPs were not installed or installed incorrectly:
Item IV.
The Permittee shall conduct turbidity monitoring in accordance with Part V of the permit:
1. YES NO Is this facility a Priority Construction Site?
2. YES NO Has the facility disturbed greater than 10 acres?
3. YES NO Was the site discharging at the time of inspection?
4. YES NO Samples collected, if “Yes”, sampling data must be attached.
