If requested, submit form to: Water II Branch Manager, ECED, MDEQ, PO Box 2261, Jackson, MS 39225
Annual SWPPP Evaluation Form for Calendar Year _______
Instructions: The SWPPP shall describe and ensure the implementation of BMPs which will reduce pollutants in storm
water discharges and assure compliance with the terms and conditions of the RMCGP permit. The SWPPP must be
evaluated annually to ensure the effectiveness of the SWPPP's design and implementation. [2020 RMCGP ACT5, T-2, T-3,
and T-7]
Company/Facility Name: Person evaluating SWPPP:
SWPPP Components and Description of Potential Pollutant Sources [Condition T-2, ACT 5]
Identifies industrial activities exposed to storm water. [T-2(1)]
Describes materials and pollutants associated with the activities above. [T-2(2) & (3)]
Identifies spill and leaks of toxic or hazardous pollutants. [T-2(4)]
Identifies pollutants of concern and summarizes storm water sampling data. [T-2(5)]
Includes a detailed scaled site map and a topographical map. [T-2(6) & (7)]
Identifies pollutants likely present and a reasonable potential for containment. [T-2(8)]
SWPPP Components and Description of Storm Water Management Controls [Condition T-3, ACT 5]
Identifies position(s) responsible for developing, implementing, maintain, and revising SWPPP. [T-3(1)]
Lists materials handled, assesses and identifies risk of potential pollution, and specifies necessary controls. [T-3(2)]
Identifies areas with a high potential for soil erosion and prevention measures. [T-3(3)]
Identifies a preventive maintenance program. [T-3(4)]
Identifies good housekeeping practices. [T-3(5)]
Identifies potential spill areas, their drainage points, and procedures for cleaning spills. [T-3(6)]
Identifies personnel training responsible for implementing and/or complying with the SWPPP. [T-3(7)]
Certifies storm water testing every 5 yrs. when feasible for non-allowed, non-storm water discharges. [T-3(8)]
Identifies areas to be inspected monthly for objectionable characteristics. [T-3(9)]
Identifies allowable non-storm water discharges and appropriate BMPs for the non-storm water. [T-3(10)]
Provides management of storm water volume through its diversion, infiltration, storage, or re-use. [T-3(11)]
SWPPP Certification and Signature
The SWPPP is on-site, current, adequately addresses the sources of pollution at the facility, is fully compliant with
the terms and conditions of the RMCGP and effectively controls storm water pollutants. If no, the SWPPP shall be
amended and submitted to MDEQ within 30 days of amendment. [ACT 2, S-5, ACT5 T-4(4)]
I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed
to assure that qualified personnel properly gathered and evaluated 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 am aware that there are significant penalties for submitting false
information, including the possibility of fines and imprisonment for knowing violations.
Authorized Signature of Responsible Official Date
Printed Name Title
* A responsible official according to 2020 RMCGP, ACT 6, T-9