If requested, submit signed form to Water II Branch Manager, ECED, MDEQ, PO Box 2261, Jackson, MS 39225
MONTHLY SPILL & LEAK LOG
READY-MIX CONCRETE GENERAL PERMIT
Facility Name:_____________________
Coverage Number: MSG11__ __ __ __
Month: ________________
Year: ___________
Instructions: A list of spills and leaks of toxic or hazardous pollutants that have occurred at the facility shall be documented on the Monthly Spill and Leak
Log Sheet provided by MDEQ at www.mdeq.ms.gov/rmcgp. A separate form shall be completed for each month that the facility is covered under this general
permit. If no spills have occurred, the form shall be completed by checking the first box and signing at the bottom, as indicated. Coverage recipients may
use an alternate form to record this information, so long as it includes all of the information in this form and it is updated monthly. The completed monthly
forms shall be filed on-site with the SWPPP and made available to MDEQ personnel for inspection upon request. [2020 RMCGP ACT5 T-2(4)]
No spills have occurred this month.
Date of Spill Material Spilled
Quantity Spilled
(specify units)
Area of Spill
Did spill result
in a discharge?
(Yes/No)
Injury / Property
Damage?
(Yes/No)
Person(s) involved in
cleanup
Date reported
to MDEQ
(if significant)
Corrective Actions(s) Taken:
Date of Spill Material Spilled
Quantity Spilled
(specify units)
Area of Spill
Did spill result
in a discharge?
(Yes/No)
Injury / Property
Damage?
(Yes/No)
Person(s) involved in
cleanup
Date reported
to MDEQ
(if significant)
Corrective Actions(s) Taken:
Date of Spill Material Spilled
Quantity Spilled
(specify units)
Area of Spill
Did spill result
in a discharge?
(Yes/No)
Injury / Property
Damage?
(Yes/No)
Person(s) involved in
cleanup
Date reported
to MDEQ
(if significant)
Corrective Actions(s) Taken:
“I certify under penalty of law that this report is true, accurate, and complete, to the best of my knowledge and belief.”
Inspector Name: Inspector Signature: Date:
