SELF MONITORING REPORT
DEPARTMENT OF ENVIRONMENTAL SERVICES - PRETREATMENT DIVISION
City of Baton Rouge - Parish of East Baton Rouge, 345 Chippewa St., Baton Rouge, LA 70805
Telephone: (225) 389-5456 Fax: (225) 389-5640
For Pretreatment Division use only
cc: Albert Leo N. dela Cruz, Ph.D., Environmental & Wastewater Pretreatment Manager Q:\CPEBR\SMRForm_2016.doc
Sarah Boudreaux, Environmental Coordinator Revised 09/2016
Page 1
INDUSTRIAL USER INFORMATION:
Person completing
report:
Industrial Users: Completion of the Self Monitoring Report is required by the Industrial User Permit issued to your facility
. Refer to
your permit, Part II for reporting requirements. To complete this form, please address every section, check all the boxes that apply,
and submit all information as required. Record only the information FOR THIS REPORTING PERIOD as specified in your permit.
Failure to accurately complete this report may result in non-compliance with the City-Parish pretreatment regulation.
COMPLIANCE STATUS:
Permit (CHOOSE ONE)
I hereby certify that the facility and operations are in compliance with the Industrial User Permit during this reporting period.
The facility and operations are NOT in compliance with the Industrial User Permit during reporting period. An explanation is attached.
Local/Federal Limits (CHOOSE ONE IF SAMPLES ARE COLLECTED)
All analytical and/or monitoring results are within the required applicable local/federal limits. Attach all required documentation. (The
documentation include but not limited to: State certified laboratory name, address, telephone number; reporting limits; units; QA/QC data;
completed Chain of Custody reports; Signed Verification of Sample Collection and Handling Procedures Form and Verification of Data Accuracy
Form; Flow measurement reports, Special documents as requested by the Pretreatment Division).
Analytical and/or monitoring results indicate violation(s) of required applicable local/federal limits. A separate sheet is attached listing the
violation (s), the reason for violation(s), and a description of corrective action(s) taken.
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Section 2:276.
2
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Sections 2:268.
3
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Sections 2:253.
Certification Statement
(Required for all user report submittals
2
)
"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(s) 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 fine and imprisonment for knowing violations."
________________________________ ______________________________ _________________
Signature of Authorized Representative
3
Title & Company Date
click to sign
signature
click to edit
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