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ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM) NPDES (State of Alabama)

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ADEM Form 23 m1 04/2020 Page 1 of 2
Instructions: Please complete all questions. Respond with “N/A” as appropriate. Forms with incomplete or incorrect answers, or
missing signatures will delay processing and may result in appropriate compliance action by the Department.
ITEM I.
Permittee Name: Facility/Site Name:
Permit Number: County:
Facility/Site Entrance Latitude & Longitude: Phone Number:
Facility/Site 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 #
ITEM III.
YES NO
1. 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):
YES NO
2. Were BMPs properly implemented and maintained at the time of inspection?
If “No”, please provide location(s) and descriptions of BMPs that need maintenance:
YES NO
3. 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:
YES NO
4. Have any BMPs failed to operate as designed?
If “Yes”, please provide location(s) and description of BMP(s) that failed:
YES NO
5. 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:
ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM)
NPDES
CONSTRUCTION STORMWATER INS
PECTION REPORT AND BMP CERTIFICATION
ADEM Form 23 m1 04/2020 Page 2 of 2
ITEM IV.
Weather Conditions:
Discharge
Point #
Date, Time, and Location of Samples Collected Sample Results Analytical Method(s)
“Based upon an inspection conducted on _______________________________ (Date & Time) by the QCP, QCI, or a qualified person
(List Name(s):_______________________________________________________________) under the direct supervision of the QCP identified
below, the QCI or QCP identified below certifies that effective structural and non-structural BMPs have been fully implemented and regularly
maintained to the maximum extent practicable for the prevention and minimization of all sources of pollution in stormwater and authorized related
process wastewater runoff, except for those deficiencies noted above, in accordance with the facility’s CBMPP, good sediment, erosion, and other
pollution control practices, and the requirements of the permit. I certify that discharges have been tested or evaluated for the presence of non-stormwater
and non-authorized process wastewaters. 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 gather and evaluate 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 certify that this form has not been altered, and if copied or
reproduced, is consistent in format and identical in content to the ADEM approved form. I am aware that there are significant penalties for submitting
false information, including the possibility of fines and imprisonment for knowing violations.”
Name & Designation of QCI or QCP
Signature
Date
Name & Title of Permittee Responsible Official
Signature
Date
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ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM) NPDES (State of Alabama)

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Completed 4 October 2021

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