RULE 6 STORM WATER POLLUTION PREVENTION PLAN (SWP3) CERTIFICATION CHECKLIST For questions regarding this form, contact: State Form 51287 (R5 / 1-09) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used, completed, and submitted within one (1) year after an NOI letter is received by IDEM for permit coverage under a general NPDES permit pursuant to 327 IAC 15-6. IDEM – Rule 6 Coordinator 100 North Senate Avenue, Rm 1255 Mail Code 65-42 Indianapolis, IN 46204 Phone: (317) 233-0202 or (800) 451-6027, ext. 30202 (within Indiana) Web Access: http://www.in.gov/idem/4901.htm Return this form by mail to the IDEM Rule 6 Coordinator at the address listed in the box on the upper-right. PART A: GENERAL INFORMATION FOR FACILITY 1. Facility name 2. Facility general NPDES Industrial Storm Water Permit Number Number and street 3. Facility location address ZIP code City INRCounty PART B: RULE 6 CHECKLIST ► Please check the appropriate box when the requirements for each numbered item have been met, or check NA if an item is “not applicable.” For some of the numbered items, the requirements must be met and “not applicable” is not provided as an option. NA ITEM 1. 2. 3. 4. 5. Plan identifies individuals and their corresponding responsibilities for the facility Storm Water Pollution Prevention Team Plan contains a copy of the complete NOI letter, which contains: i) Facility contact information ii) SIC Code(s) iii) Facility longitude and latitude iv) Receiving water(s) v) The identification of past and present NPDES permits vi) The identification of the MS4 receiving the storm water discharge(s) vii) Narrative description of industrial processes at facility viii) Responsible Individual contact information ix) Registered Agent contact information x) Outfall description, which identifies substantially similar outfall discharges and monitoring points xi) Proof of publication Plan contains a soils map, which indicates the types of soils found on the facility property. The boundaries of the facility property have been outlined, in a contrasting color. If a facility’s property only has impervious surfaces, the soils map requirement can be omitted. 1 Graphical representation which indicates : i) On-site drainage and discharge conveyances ii) Adjacent property drainage and discharge conveyances iii) On-site and adjacent property water bodies iv) Outline of the drainage area for each storm water outfall v) Outline of the facility property indicating directional flows of surface drainage patterns vi) Outline of the impervious surfaces, with estimate of impervious and pervious surfaces square footage for each drainage area vii) On-site injection wells viii) On-site wells used as potable water sources ix) Existing structural control measures 2 x) Existing and/or historical underground and aboveground storage tank locations 2 xi) Permanently designated plowed and/or dumped snow storage locations 2 xii) Loading and unloading areas for solid and/or liquid bulk materials xiii) Existing and/or historical outdoor storage areas for raw materials, intermediary products, final products, or waste 2 materials 2 xiv) Existing and/or historical outdoor storage areas for fuels, processing equipment, and other containerized materials 2 xv) Outdoor processing areas 2 xvi) Dust or particulate generating process areas 2 xvii) Outdoor waste storage and/or disposal areas 2 xviii) Pesticide and/or herbicide application areas 2 xix) Vehicular access roads Area map which indicates: i) Topographic relief or similar elevations ii) Facility outlined in contrasting color iii) Receiving water(s) iv) Drinking water wells within a ¼-mile radius (Continued on page 2) 1 The on-site mapping of items listed in (x) through (xix) is required only in those areas that generate storm water discharges exposed to industrial activity and have a reasonable potential for storm water exposure to pollutants. 2 The mapping of historical locations is only required if the historical locations have a reasonable potential for storm water exposure to historical pollutants. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com PART B: RULE 6 CHECKLIST ► Please check the appropriate box when the requirements for each numbered item have been met, or check NA if an item is “not applicable.” For some of the numbered items, the requirements must be met and “not applicable” is not provided as an option. NA ITEM 6. 3 Plan contains a narrative description of potential pollutant source areas a) Descriptions have been created for all existing and/or historical areas identified as being a potential source of storm water exposure to pollutants. b) The descriptions for EACH area includes: i) Type and typical quantity of materials present in the area ii) Methods of storage, including presence of any secondary containment measures iii) Remedial actions undertaken in the area to eliminate pollutant sources or exposure of storm water to those sources 3 iv) Spill or leak history in the area (1) Date and type of material released (2) Estimated volume released (3) Description of remedial actions undertaken c) Where the chemical or material can be exposed to storm water, area contains a risk identification analysis of chemicals or materials stored or used within the area, which includes: i) Toxicity data of chemicals and/or materials used within the area, referencing appropriate MSDS locations ii) Frequency and typical quantity of chemicals and/or materials stored in the area iii) Potential ways storm water discharges may be exposed to chemicals and/or materials iv) Likelihood of the chemicals and/or materials to come into contact with storm water 7. Plan contains a narrative description of existing and planned management practices and measures to improve the quality of, or eliminate, storm water run-off leaving the facility property a) Descriptions have been created for all existing and/or historical areas identified as being a potential source of storm water exposure to pollutants, including those areas listed in the graphical representation required by the SWP3. The description includes: i) Existing and planned structural and nonstructural control practices and measures for EACH area ii) Any treatment the storm water receives prior to leaving the facility property or entering a water of the state iii) Ultimate disposal of any solid or fluid wastes collected in structural control measures b) Specific control practices and measures are utilized, and include: i) Identification of areas which have a high potential for significant soil erosion, including implementation of erosion control measures ii) Plan created to reduce exposure of storm water to storage piles of sand, salt, or other commercial/industrial materials iii) Storage piles of sand, salt, or other commercial/industrial materials are stored in a manner to reduce the potential for polluted storm water run-off c) The facility has a written preventative maintenance program i) Implementation of good housekeeping practices to reduce the potential for storm water contact with pollutants ii) Documentation of storm water control measure maintenance iii) Documentation of the inspection and testing of facility equipment and systems that have potential exposure to storm water iv) Documentation of quarterly storm water control measure inspections v) Documentation of quarterly storm water run-off conveyances inspections vi) Documentation of annual training for all employees that have the potential to engage in industrial activities that impact storm water quality d) The facility has a written spill response program i) Location, description, and quantity of all response materials and equipment ii) Response procedures for facility personnel iii) Contact information for reporting spills, both for facility staff and external emergency response entities e) The facility has a written nonstorm water assessment program i) Certification letter stating that storm water discharges from the facility property or entering a water of the state have been evaluated for the presence of illicit discharges and non-storm water contributions ii) Detergent or solvent-based washing of equipment or vehicles that would allow washwater additives to enter any storm drainage system or receiving water shall not be allowed at the facility, and the corrective action is documented in the written nonstorm water assessment program iii) Maintenance area floor drains with the potential for maintenance fluids or other materials to enter storm sewers are sealed, connected to a sanitary sewer with prior authorization, or the discharge is permitted under an appropriate NPDES wastewater permit, and the corrective action is documented in the written nonstorm water assessment program iv) For conducting the nonstorm water assessment, a description of the method used, the date of any testing, and the on-site drainage points that were directly observed during a test 8. Plan contains the analytical results of run-off monitoring a) Monitoring data includes field data sheets, chain-of-custody forms, and laboratory results b) Comparison created after the results of two sample monitoring events is available i) Pollutant investigated when reductions are not indicated in the comparison, where appropriate ii) Practices and/or measures implemented as a result of the investigation are documented 9. If applicable, plan references other facility pertinent plans (e.g. Operations and Maintenance, Spill Prevention Control and Countermeasures, or Risk Contingency Plans) 10. Plan has been certified by a qualified professional 11. Plan is retained and available at the facility 12. Plan has been completed and implemented 365 days after submission of a timely-submitted NOI letter, or prior to initiation of operations at the facility 3 Spill or leak history shall date back for a period of three (3) years from the date of the NOI letter, in the identified area, for materials spilled outside of secondary containment structures and impervious surfaces in excess of their reportable quantity. In subsequent permit terms, the history shall date back for a period of five (5) years from the date of the NOI letter. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com PART C: GENERAL INFORMATION REGARDING THE SWP3 • • The SWP3 must be reviewed periodically for changes and improvements at the facility. As a minimum, this review should be conducted annually. The dates of all SWP3 reviews should be documented in the SWP3. As changes and improvements to the original SWP3 are made, the SWP3 must be updated, and retained and available at the facility. The SWP3 checklist shall be completed and submitted to IDEM: Within 365 days after submission of an initial, renewal, or amended NOI letter; or Upon the written or verbal request of an IDEM representative. PART D: CERTIFICATION AND SIGNATURE • Make sure you have completed all appropriate sections of this SWP3 checklist. Sign and date the bottom of this form and return it to the address shown on page one (1) of this SWP3 checklist. • All information requested in this SWP3 checklist is MANDATORY, unless noted otherwise, for the administration and processing of your permit pursuant to 327 IAC 15-6. All data received will be regarded as a public record. ► The person referenced in PART A, Item #10 of this form (Qualified Professional) must sign the following certification statement: “By signing this SWP3 checklist, I hereby 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 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.” Type or print Qualified Professional Name: Signature of Qualified Professional: Date: (mm/dd/year) Date: (mm/dd/year) Type or print Responsible Individual Name: Signature of Responsible Individual: Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com