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VIDPNR Permit No: VIR050000 - Notice Of Intent (NOI) Page 1 of 7 USVI Department of Planning and Natural Resources ANNUAL REPORTING FORM For the TPDES Multi-Sector General Permit (VI MSGP) General Permit No. VIR050000 A. General Information 1. Facility Name: ______________________________________________________________________________ 2. TPDES VI MSGP Tracking No: 3. Facility Physical Address: _____________________________________________________________________________ _____________________________________________________________________________ 4. Contact Person’s Name: _________________________________________Title: ________________________________ 5. Phone: (_____)_______________ 6. Fax: (_____)_______________ 7. Email: _____________________________________________________________________________________ B. General Findings 1. Provide a summary of your past year’s routine facility inspection documentation (see Part 3.1.2 of the permit). VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 2 of 7 2. Provide a summary of your past year’s quarterly visual assessment documentation (see Part 3.2.2 of the permit). 4. Did you review stormwater monitoring data as part of this inspection to identify potential pollutant hot spots? If YES, summarize the findings of that review and describe any additional inspection activities resulting from this review: VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 3 of 7 5. Describe any evidence of pollutants entering the drainage system or discharging to surface waters, and the condition of and around outfalls, including flow dissipation measures to prevent scouring: 6. Have you taken or do you plan to take any corrective actions, as specified in Part 3 of the permit, since your last annual report submission (or since your received authorization to discharge under this permit if this is your first annual report), including any corrective actions identified as a result of this annual comprehensive site inspection? If YES, how many conditions requiring review for correction action as specified in Parts 3.1 and 3.2 were addressed by these corrective actions?: ___________ NOTE: Complete the attached Corrective Action From (Section D) for each condition indentified, including any conditions identified as a result of this comprehensive stormwater inspection. VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 4 of 7 C. Industrial Activity Area Specific Findings Complete one block for each industrial activity area where pollutants may be exposed to stormwater. Copy this page for additional industrial activity areas. In reviewing each area, you should consider:  Industrial materials, residue, or trash that may have or could come into contact with stormwater;  Leaks or spills from industrial equipment, drums, tanks, and other containers;  Offsite tracking of industrial or waste materials from areas of no exposure to exposed areas; and  Tracking or blowing of raw, final, or waste materials from areas of no exposure to exposed areas. INDUSTRIAL ACTIVITY AREA ______: 1. Brief Description: 2. Are any control measures in need of maintenance or repair? 3. Have any control measures failed and require replacement? 4. Are any additional/revised control measures necessary in this area? If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached Corrective Action Form) INDUSTRIAL ACTIVITY AREA ______: 1. Brief Description: 2. Are any control measures in need of maintenance or repair? 3. Have any control measures failed and require replacement? 4. Are any additional/revised control measures necessary in this area? If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached Corrective Action Form) VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 5 of 7 INDUSTRIAL ACTIVITY AREA ______: 1. Brief Description: 2. Are any control measures in need of maintenance or repair? 3. Have any control measures failed and require replacement? 4. Are any additional/revised control measures necessary in this area? If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached Corrective Action Form) INDUSTRIAL ACTIVITY AREA ______: 1. Brief Description: 2. Are any control measures in need of maintenance or repair? 3. Have any control measures failed and require replacement? 4. Are any additional/revised control measures necessary in this area? If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached Corrective Action Form) INDUSTRIAL ACTIVITY AREA ______: 1. Brief Description: 2. Are any control measures in need of maintenance or repair? 3. Have any control measures failed and require replacement? 4. Are any additional/revised control measures necessary in this area? If YES to any of these three questions, provide a description of the problem: (Any necessary corrective actions should be described on the attached Corrective Action Form) VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 6 of 7 D. Corrective Actions Complete this page for each specific condition requiring a corrective action or a review determining that no corrective action is needed. Copy this page for additional corrective actions or reviews. Include both corrective actions that have been initiated or completed since the last annual report, and future corrective actions needed to address problems identified in this comprehensive stormwater inspection. Include an update on any outstanding corrective actions that had not been completed at the time of your previous annual report. 1. Corrective Action No. of for this reporting period. 2. Is this corrective action: An update on a corrective action from a previous annual report; or A new corrective action? 3. Identify the condition(s) triggering the need for this review: Unauthorized release or discharge Numeric effluent limitation exceedance Control measures inadequate to meet applicable water quality standards Control measures inadequate to meet non-numeric effluent limitations Control measures not properly operated or maintained Change in facility operations necessitated change in control measures Average benchmark value exceedance Other (describe): ________________________________ 4. Briefly describe the nature of the problem identified: 5. Date problem identified: / / 6. How problem was identified: Comprehensive site inspection Quarterly visual assessment Routine facility inspection Benchmark monitoring Notification by VIDPNR, EPA or other regulating agencies Other (describe): ________________________________ VIDPNR Permit No: VIR050000 – Annual Reporting Form Page 7 of 7 7. Description of corrective action(s) taken or to be taken to eliminate or further investigate the problem (e.g., describe modification or repairs to control measures, analyses to be conducted, etc.) or if no modifications are needed, basis for that determination: 8. Did/Will this corrective action require modification of your SWPPP? 9. Date corrective action initiated: / / 10. Date corrective action completed: / / or expected to be completed: / / 11. If corrective action not yet completed, provide the status of corrective action at the time of the comprehensive site inspection and describe any remaining steps (including timeframes associated with each step) necessary to complete corrective action: E. Annual Report Certification 1. Compliance Certification Do you certify that your annual inspection has met the requirements of Part 4.2 of the permit, and that, based upon the results of this inspection, to the best of your knowledge, you are incompliance with the permit? If NO, summarize why you are not in compliance with the permit: 2. Annual Report Certification 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. Authorized Representative Printed Name: ______________________________________ Title:________________________________ Signature: ______________________________________ Date:_______________________________