Additional msgp documentation insert facility name insert facility permit tracking number




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Additional MSGP Documentation

INSERT FACILITY NAME INSERT FACILITY PERMIT TRACKING NUMBER




Additional MSGP Documentation Template
Introduction

After you become permitted under the 2008 MSGP, you are required to keep certain minimum records (or documentation) as part of the implementation of your permit responsibilities. As required in Part 5.4 of the 2008 MSGP, these records must be kept in the same place your SWPPP (which you completed prior to submitting your NOI to be covered) is kept. This “Additional MSGP Documentation Template” (or “Template”) will assist you in complying with this requirement.



Using the Additional MSGP Documentation Template
Tips for using the Template:

  • This Template is designed for use by all facilities permitted under the 2008 MSGP. The Template is NOT tailored to your individual industrial sector. Depending on which industrial sector(s) you fall under (see Appendix D of the 2008 MSGP) and where your facility is located (see Appendix C of the 2008 MSGP), you will need to address any additional documentation requirements outlined in Part 8 and/or Part 9 of the permit, respectively.

  • Each section of the template includes “instructions” and space for your facility’s specific information. You should read the instructions before you complete each section. The text you will need to complete is generally indicated through the use of blue form fields (e.g., “Insert Facility Name”). Click on the form field and your text will replace the instructional text.

  • The Template was developed in Microsoft Word so that you can easily add tables and additional text.

  • Because many of the activities you are required to document occur throughout the permit term, you will need to continually modify and add records to this Template. You may wish to create separate electronic files for each category of documentation (e.g., files for monitoring, employee training, etc.) so that they can be easily modified.

  • The records you create using this Template must be kept in the same location as your SWPPP.

EPA notes that while EPA has made every effort to ensure the accuracy of all instructions and guidance contained in the Template, the actual obligations of regulated industrial facilities are determined by the relevant provisions of the permit, not by the Template. In the event of a conflict between the Template and any corresponding provision of the MSGP, the permit provisions establish your actual requirements. EPA welcomes comments on the Template at any time and will consider those comments in any future revision of this document.





Additional MSGP Documentation
For:
Insert Facility Name

Insert Facility Address

Insert City, State, Zip Code

Insert Facility Telephone Number (if applicable)

Insert Facility Permit Tracking Number

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Contents


A. Significant spills, leaks or other releases 1

B. Employee training 2

C. Maintenance 4

D. Routine Facility Inspection Reports 6

E. Quarterly Visual Assessment Reports 10

F. Comprehensive Site Inspection Reports 12

G. Monitoring results 13

H. Deviations from assessment or monitoring schedule 14

I. Benchmark Exceedances 15

J. Impaired Waters Monitoring: Documentation of Natural Background Sources or Non-Presence of Impairment Pollutant 16

K. Active/Inactive status change 17

L. SWPPP Amendment Log 18



M. Miscellaneous Documentation 19


A. Significant spills, leaks or other releases



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Date of incident: Insert Date of Incident

Location of incident: Insert Location of Incident

Description of incident: Insert Description of Incident

Circumstances leading to release: Describe circumstances leading to release

Actions taken in response to release: Describe actions taken in response to release

Measures taken to prevent recurrence: Describe measures taken to prevent recurrence

Date of incident: Insert Date of Incident

Location of incident: Insert Location of Incident

Description of incident: Insert Description of Incident

Circumstances leading to release: Describe circumstances leading to release

Actions taken in response to release: Describe actions taken in response to release

Measures taken to prevent recurrence: Describe measures taken to prevent recurrence

Date of incident: Insert Date of Incident

Location of incident: Insert Location of Incident

Description of incident: Insert Description of Incident

Circumstances leading to release: Describe circumstances leading to release

Actions taken in response to release: Describe actions taken in response to release

Measures taken to prevent recurrence: Describe measures taken to prevent recurrence

Date of incident: Insert Date of Incident

Location of incident: Insert Location of Incident

Description of incident: Insert Description of Incident

Circumstances leading to release: Describe circumstances leading to release

Actions taken in response to release: Describe actions taken in response to release

Measures taken to prevent recurrence: Describe measures taken to prevent recurrence

B. Employee training



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Training Date: Insert Date of Training

Training Description: Insert Description of Training

Trainer: Insert Trainer(s) names

Employee(s) trained

Employee signature

Insert Name




Insert Name




Insert Name




Insert Name




Insert Name




Insert Name






Training Date: Insert Date of Training

Training Description: Insert Description of Training

Trainer: Insert Trainer(s) names

Employee(s) trained

Employee signature

Insert Name




Insert Name




Insert Name




Insert Name




Insert Name




Insert Name






Training Date: Insert Date of Training

Training Description: Insert Description of Training

Trainer: Insert Trainer(s) names

Employee(s) trained

Employee signature

Insert Name




Insert Name




Insert Name




Insert Name




Insert Name




Insert Name



C. Maintenance



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Control Measure Maintenance Records (copy information below for each control measure)
Control Measure: Insert Name of Control Measure 

Regular Maintenance Activities: Describe maintenance activities

Regular Maintenance Schedule: Insert Maintenance Schedule
Date of Action: Insert Date of Action 

Reason for Action:  Regular Maintenance  Discovery of Problem

If Problem,

- Description of Action Required: Describe actions taken in response to problem

- Date Control Measure Returned to Full Function: Insert Date 

- Justification for Extended Schedule, if applicable: Insert Justification (if applicable)

Notes: Insert Notes (if applicable)
Industrial Equipment and Systems Maintenance Records (copy information below for each industrial equipment/system)
Industrial Equipment/Systems: Insert Name of Industrial Equipment/System

Regular Maintenance Activities: Describe maintenance activities

Regular Maintenance Schedule: Insert Maintenance Schedule
Date of Action: Insert Date of Action 

Reason for Action:  Regular Maintenance  Discovery of Problem

If Problem,

- Description of Action Required: Describe actions taken in response to problem

- Date Industrial Equipment Returned to Full Function: Insert Date 

- Justification for Extended Schedule, if applicable: Insert Justification (if applicable)

Notes: Insert Notes (if applicable)

D. Routine Facility Inspection Reports



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Stormwater Industrial Routine Facility Inspection Report

General Information

Facility Name

Insert Name

NPDES Tracking No.

Insert Tracking No.

Date of Inspection

Insert Date

Start/End Time

Insert Start/End Time

Inspector’s Name(s)

Insert Name

Inspector’s Title(s)

Insert Title

Inspector’s Contact Information

Insert Contact Info

Inspector’s Qualifications

Insert qualifications or add reference to the SWPPP

Weather Information

Weather at time of this inspection?

 Clear Cloudy  Rain  Sleet  Fog  Snow  High Winds

 Other: Temperature:


Have any previously unidentified discharges of pollutants occurred since the last inspection? Yes No

If yes, describe: Describe


Are there any discharges occurring at the time of inspection? Yes No

If yes, describe: Describe


Control Measures

  • Number the structural stormwater control measures identified in your SWPPP on your site map and list them below (add as many control measures as are implemented on-site). Carry a copy of the numbered site map with you during your inspections. This list will ensure that you are inspecting all required control measures at your facility.

  • Describe corrective actions initiated, date completed, and note the person that completed the work in the Corrective Action Log.




Structural Control Measure

Control Measure is Operating Effectively?

If No, In Need of Maintenance, Repair, or Replacement?

Corrective Action Needed and Notes

(identify needed maintenance and repairs, or any failed control measures that need replacement)



1

Insert Control Measure Name

Yes No

Maintenance

 Repair


Replacement

Describe Corrective Actions

2

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

3

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

4

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

5

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

6

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

7

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

8

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

9

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

10

Insert Control Measure Name

Yes No

 Maintenance

 Repair


 Replacement

Describe Corrective Actions

Areas of Industrial Materials or Activities exposed to stormwater

Below are some general areas that should be assessed during routine inspections. Customize this list as needed for the specific types of industrial materials or activities at your facility.





Area/Activity

Inspected?

Controls Adequate (appropriate, effective, and operating)?

Corrective Action Needed and Notes


1

Material loading/unloading and storage areas

Yes No  N/A


Yes No

Describe Corrective Actions



2

Equipment operations and maintenance areas

Yes No  N/A


Yes No

Describe Corrective Actions



3

Fueling areas

Yes No  N/A


Yes No

Describe Corrective Actions



4

Outdoor vehicle and equipment washing areas

Yes No  N/A


Yes No

Describe Corrective Actions



5

Waste handling and disposal areas


Yes No  N/A


Yes No

Describe Corrective Actions

6

Erodible areas/construction


Yes No  N/A


Yes No

Describe Corrective Actions

7

Non-stormwater/ illicit connections


Yes No  N/A


Yes No

Describe Corrective Actions

8

Salt storage piles or pile containing salt


Yes No  N/A


Yes No

Describe Corrective Actions

9

Dust generation and vehicle tracking


Yes No  N/A


Yes No

Describe Corrective Actions

10

(Other)



Yes No  N/A


Yes No

Describe Corrective Actions

11

(Other)



Yes No  N/A


Yes No

Describe Corrective Actions

12

(Other)



Yes No  N/A


Yes No

Describe Corrective Actions

Non-Compliance

Describe any incidents of non-compliance observed and not described above:

Describe Non-compliance





Additional Control Measures

Describe any additional control measures needed to comply with the permit requirements:

Describe Additional Controls Needed




Notes

Use this space for any additional notes or observations from the inspection:

Additional Notes





CERTIFICATION STATEMENT

“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 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 fine and imprisonment for knowing violations.”


Print name and title: __________________________________________________________________
Signature:_________________________________________________Date:_____________________

E. Quarterly Visual Assessment Reports



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MSGP Quarterly Visual Assessment Form

(Complete a separate form for each outfall you assess)

Name of Facility:

Name of Facility

NPDES Tracking No.

Insert Tracking No.

Outfall Name: Name

"Substantially Identical Outfall"?  No

 Yes (identify substantially identical outfalls):

Person(s)/Title(s) collecting sample: Name/Title

Person(s)/Title(s) examining sample: Name/Title

Date & Time Discharge Began:
Enter date and time

Date & Time Sample Collected:
Enter date and time

Date & Time Sample Examined:
Enter date and time

Substitute Sample?  No

 Yes (identify quarter/year when sample was originally scheduled to be collected):

Nature of Discharge:  Rainfall  Snowmelt

If rainfall: Rainfall Amount:_No of inches_inches

Previous Storm Ended > 72 hours
Before Start of This Storm?

 Yes

 No*  (explain):

Parameter

Color

 None  Other

(describe):

Odor

 None  Musty  Sewage  Sulfur  Sour  Petroleum/Gas ______________________

 Solvents  Other (describe):



Clarity

 Clear  Slightly Cloudy  Cloudy  Opaque  Other

Floating Solids

 No  Yes (describe):

Settled Solids**

 No  Yes (describe):

Suspended Solids

 No  Yes (describe):

Foam (gently shake sample)

 No  Yes (describe):

Oil Sheen

 None  Flecks  Globs  Sheen  Slick

 Other (describe):



Other Obvious Indicators of Stormwater Pollution

 No  Yes (describe):

* The 72-hour interval can be waived when the previous storm did not yield a measurable discharge or if you are able to document (attach applicable documentation) that less than a 72-hour interval is representative of local storm events during the sampling period.

** Observe for settled solids after allowing the sample to sit for approximately one-half hour.






















Detail any concerns, additional comments, descriptions of pictures taken, and any corrective actions taken below (attach additional sheets as necessary). Insert details






Certification by Facility Responsible Official (Refer to MSGP Subpart 11 Appendix B for Signatory Requirements)

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 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 fine and imprisonment for knowing violations.




A. Name:




B. Title:







C. Signature:




D. Date Signed:






F. Comprehensive Site Inspection Reports



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G. Monitoring results



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H. Deviations from assessment or monitoring schedule



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Date: Insert Date

 Visual assessments  Monitoring



Describe deviation from schedule: Describe deviation

Reason for deviation: Describe reason
Date: Insert Date

 Visual assessments  Monitoring



Describe deviation from schedule: Describe deviation

Reason for deviation: Describe reason
Date: Insert Date

 Visual assessments  Monitoring



Describe deviation from schedule: Describe deviation

Reason for deviation: Describe reason
Date: Insert Date

 Visual assessments  Monitoring



Describe deviation from schedule: Describe deviation

Reason for deviation: Describe reason


I. Benchmark Exceedances




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Date: Insert Date

Parameter Exceeded and Results: Insert Parameter Name

Quarter 1 (Sample date: Insert Sample Date) Result: Insert Sample Result

Quarter 2 (Sample date: Insert Sample Date) Result: Insert Sample Result

Quarter 3 (Sample date: Insert Sample Date) Result: Insert Sample Result

Quarter 4 (Sample date: Insert Sample Date) Result: Insert Sample Result

Average Result: Insert Value

Benchmark Value: Insert Benchmark Value from 2008 MSGP
Document how benchmark exceedance(s) responded to:

 Corrective action taken

Parameter(s): Insert Parameter 

Complete Part D (corrective actions) of the Annual Report Form (see section F of the Additional MSGP Documentation).


 Finding that the exceedence was due to natural background pollutant levels

Parameter(s): Insert Parameter 

Attach the following documentation:


  • An explanation of why you believe that the presence of the pollutant causing the impairment in your discharge is not related to the activities at your facility; and

  • Data and/or studies that tie the presence of the pollutant causing the impairment in your discharge to natural background sources in the watershed.

 Finding that no further pollutant reductions are technologically available and economically practicable and achievable in light of best industry practice consistent with Part 6.2.1.2.

Parameter(s): Insert Parameter 

Attach documentation.



J. Impaired Waters Monitoring: Documentation of Natural Background Sources or Non-Presence of Impairment Pollutant



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Date: Insert Date

Check one of the boxes below and complete the additional documentation:

 #1 – Pollutant(s) for which the water is impaired is not present and not expected to be present in your discharge

Attach documentation that the impairment pollutant(s) was not detected in your discharge sample(s).


 #2 – Pollutant(s) for which the water is impaired is present, but you have determined its presence is caused solely by natural background sources.

Attach the following documentation:



  • An explanation of why you believe that the presence of the pollutant(s) causing the impairment in your discharge is not related to the activities at your facility; and

  • Data and/or studies that tie the presence of the pollutant(s) causing the impairment in your discharge to natural background sources in the watershed.


K. Active/Inactive status change




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Date: Insert Date of Change in Status

New Facility Status:  Inactive and Unstaffed  Active

Reason for change in status: Describe reason

L. SWPPP Amendment Log



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Amend. No.

Description of the Amendment

Date of Amendment

Amendment Prepared by [Name(s) and Title]

1

Insert description of amendment

Insert date

Insert name/title

2

Insert description of amendment

Insert date

Insert name/title

3

Insert description of amendment

Insert date

Insert name/title

4

Insert description of amendment

Insert date

Insert name/title

5

Insert description of amendment

Insert date

Insert name/title

6

Insert description of amendment

Insert date

Insert name/title

7

Insert description of amendment

Insert date

Insert name/title

8

Insert description of amendment

Insert date

Insert name/title

9

Insert description of amendment

Insert date

Insert name/title

10

Insert description of amendment

Insert date

Insert name/title

11

Insert description of amendment

Insert date

Insert name/title



M. Miscellaneous Documentation



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EPA Additional MSGP Documentation Template, January 13, 2009




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