If requested, submit form to Water II Branch Manager, ECED, MDEQ, PO Box 2261, Jackson, MS 39225
MONTHLY STORM WATER INSPECTION FORM
READY-MIX CONCRETE GENERAL PERMIT
Facility Name: ______________________ Coverage Number: MSG11 __ __ __ __ Date: _________
Instructions: Conduct a monthly inspection of all industrial activities exposed to storm water and the storm water outfalls. Inspect
each area/equipment noted below for indications of potential storm water contamination or failure of best management practices
required by the SWPPP, recording any issues and corrective action taken. Such inspection should be conducted during or immediately
following a rain event producing runoff, if possible. Also, for any monthly inspection performed during or after a rain event, collect storm
water runoff from each outfall in a clean, clear jar and examine it in a well-lit area. Should any objectionable characteristics described
below be observed, the coverage recipient shall investigate upstream from the sample location to identify the potential sources of
pollution and implement corrective action(s). [2020 RMCGP ACT5, T-6]
Was the inspection conducted during or
following a rain event resulting in runoff?
Yes No
If yes, were samples collected
for visual examination?
Yes No N/A
Areas/Equipment Inspected
Issues Noted?
Describe any issues noted and corrective action taken.
Yes No N/A
Truck Wash/Cleaning Area
Equipment Fueling/Maintenance Areas
Tanks, Silos, Hoppers and Dust Collection
Truck Loading Area
Outdoor Storage Piles
Sludge Dewatering Area
General Site-Wide Housekeeping
Other:
Outfall Number / Location of Sample: Time:
Parameter Parameter Description Yes No
If yes, provide a description and any corrective
action taken.
Color Is the water sample colored?
Clarity Is the water sample clear and transparent?
Floating
Solids
Are there solids floating at the top of the
sample?
Settled
Solids
Are there solids settled out in the bottom of
the sample?
Suspended
Solids
Are there solids suspended in the water
column of the sample?
Foam
Is there foam forming at the top of the
sample?
Odor Does the sample have an odor?
Oil Sheen Does the sample have an oil sheen?
“I certify under penalty of law that this report is true, accurate, and complete to the best of my knowledge and belief.”
Inspector Name (printed) Inspector’s Signature Date
