Fillable Form 1.: Inspection & Maintenance Agreement - Goodlettsville, (City of Goodlettsville, Tennessee)

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Form 1.: Inspection & Maintenance Agreement - Goodlettsville, (City of Goodlettsville, Tennessee)

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The Form 1.: Inspection & Maintenance Agreement - Goodlettsville, (City of Goodlettsville, Tennessee) form is 4 pages long and contains:

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  • 42 check-boxes
  • 68 other fields

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U.S.A. forms for City of Goodlettsville, Tennessee

BROWSE CITY OF GOODLETTSVILLE, TENNESSEE (TN) FORMS

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Page 1 of 4
Warren Garrett / Stormwater Coordinator - City of Goodlettsville - 105 S. Main Street, Goodlettsville, TN
wgarrett@goodlettsville.gov - 615-851-3462
Inspection & Maintenance Agreement - Goodlettsville, TN
Annual Maintenance Report Form
1.
This form is to be completed by an owner or operator of a property with stormwater control measures on site.
2.
The form is designed to be completed on the web and can be done with a mobile phone.
3.
The purpose is to report on the operation and maintenance of stormwater control measures.
4.
Return this report by July 1 of each year, covering the previous calendar year January through December.
5.
Completing the web-based form will take only about six minutes.
Date:
What is the address of the facility/operation? *Required
________________________________________________________________________________
Your answer
What is Owners Name and Address of Parcel? * Required
________________________________________________________________________________
Your answer
What is your name? * Required
(e.g. John Smith)
________________________________________________________________________________
Your answer
Your e-mail address
______________________________________________________________________________
Your answer
Facility manager
Please provide name of the primary manager of the operation. Facility manager, property manager, HOA
president, etc.
________________________________________________________________________________
Your answer
Facility phone number * Required
Please provide an on-site phone number.
_______________________________________
Your answer
*Required
Page 2 of 4
Warren Garrett / Stormwater Coordinator - City of Goodlettsville - 105 S. Main Street, Goodlettsville, TN
wgarrett@goodlettsville.gov - 615-851-3462
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Check box for the type of stormwater control measure(s) on site. * Required
Stormwater Control Measures (SCMs)
Click ALL check boxes that apply
Bioretention
Green roof
Channel (grass)
Inlet filter
Filter strip
Pervious concrete
Infiltration trench
Pervious paver blocks
Paver blocks
Sand filter
Rain garden
Wetland
Swale
WQPA (streamside vegetation buffer)
Manufactured
Detention basin or pond
Cistern
Underground detention chambers (e.g., plastic, concrete, corrugated metal pipe)
I believe we have stormwater controls, but I don't know what type.
None. I'm not aware of any stormwater control measures here.
Other:
Indicate the three most costly stormwater quality-related maintenance
activities at this facility the past year.
* Required (Click ALL check boxes that apply)
Vegetation management (bioretention, grass channels, swales, etc.
Litter pick-up and disposal
Brush and leaves removal (blocked pipes, outlets, etc.)
Sweeping (sediment, litter) and disposal
Minor removal of sediment from curbs, collars, forebays
Replenishing soil media in bioretention, swale or other infiltration-type SCMs
Repairing areas of erosion
Replacing plant material
Replacing stormwater treatment filters
Vacuuming litter and sediment from underground, manufactured devices
Repairing hard structures (pipe, box, headwall)
Major removal of sediment (e.g. de-mucking pond)
I'd be guessing -- I really don't know.
We didn't do any maintenance the past year.
Other:
Page 3 of 4
Warren Garrett / Stormwater Coordinator - City of Goodlettsville - 105 S. Main Street, Goodlettsville, TN
wgarrett@goodlettsville.gov - 615-851-3462
To the best of your knowledge, are all parts of your stormwater quality controls
functioning properly?
* Required (At end of this survey is a Comment box, where you may elaborate on
this question.)
☐
Yes
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No
☐Unsure
How many pounds of litter, trash and floating debris were removed from the
SCMs over the past year?
* Required
If you are not already doing so, begin to quantify the amount of litter captured in your stormwater control
measures. Keep a tally for the year. Use a whole number. If zero, enter 0. If no record or estimate is
available,
enter 1.
_______________________________________
Your answer
How many pounds of sediment were removed from the controls over the past
year?
* Required
If you are not already doing so, begin to quantify the amount of sediment (dirt, fines, grit) captured and removed
from your stormwater control measures. Keep a record for the year. Use a whole number. If zero, enter 0. If
no
record or estimate is available, enter 1.
_______________________________________
Your answer
If your stormwater treatment includes an underground, manufactured device
(vault, swirl, filter, etc.), how many times this past year was the device
INSPECTED?
Inspection of underground device normally requires lifting a grate or cover in order to view condition and contents
of device. A measuring rod is usually used to measure depth of sediment. If you have no devices, check the
N/A
columns. If one device, answer for the one, and check N/A for the other rows. If two, answer for the two
and N/A
for others. Etc. If more than four, answer for the four you inspected most. It will help if you turn your
phone to
landscape mode to see this question. (For purposes of this questionnaire, you will need to note on
your
stormwater management plan the numbering of MTDs on your site. Keep this consistent year to year for
this
annual report.)
Place “X” in appropriate boxes
N/A – NO
Device
ZERO
ONCE
TWICE
3+
Times
Unsure
Device # 1
Device # 2
Device # 3
Device # 4
Page 4 of 4
How many times was the manufactured device (vault, swirl, filter, etc.) EMPTIED
of litter, debris and/or sediment?
If you have no devices, check the N/A columns. If one device, answer for the one, and check N/A for the other
rows. If two, answer for the two and N/A for others. Etc. If more than four, answer for the four you emptied most.
Place “X” in appropriate boxes.
N/A – NO
Device
ZERO
ONCE
TWICE
3+
Times
Unsure
Device # 1
Device # 2
Device # 3
Device # 4
Do you use a contractor to service your stormwater control measures? * Required
For example, landscaping service for bioretention; or stormwater services company to vacuum underground
sediment capture devices?
☐
Yes
☐No
Name(s) of service companies
If possible, enter the company name(s), separated by commas.
_______________________________________________________________________________
Your answer
Do you (or your landscaping service company) apply fertilizer on the grounds?
* Required
Regularly (more than once per year)
Infrequently (once per year or two)
Less than once per two years
Less than once per five years
Unsure/don't know.
Include dates of inspections, remedial actions taken to repair, modify or
reconstruct the system and the state of control measures. *Required
No
Warren Garrett / Stormwater Coordinator - City of Goodlettsville - 105 S. Main Street, Goodlettsville, TN
wgarrett@goodlettsville.gov - 615-851-3462
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Form 1.: Inspection & Maintenance Agreement - Goodlettsville, (City of Goodlettsville, Tennessee)

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Completed 3 August 2020

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