Rule 6 Storm Water Pollution Prevention Plan (SWP3) Certification Checklist {51287}

RULE 6 STORM WATER POLLUTION PREVENTION PLAN (SWP3) CERTIFICATION CHECKLIST State Form 51287 (R3 / 6-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used, completed, and submitted within three hundred sixty-five (365) days after an NOI letter is received by IDEM for permit coverage under a general NPDES permit pursuant to 327 IAC 15-6. Return this form by mail to the IDEM Rule 6 Coordinator at the address listed in the box on the upper-right. For questions regarding this form, contact: IDEM ­ Rule 6 Coordinator 100 North Senate Avenue, Rm 1255 P.O. Box 6015 Indianapolis, IN 46206-6015 Phone: (317) 233-0202 or (800) 451-6027, ext. 30202 (within Indiana) Web Access: http://www.in.gov/idem/permits/water/wastewater/wetwthr/storm PART A: GENERAL INFORMATION FOR FACILITY 1. 2. 3. Facility name: Facility general NPDES Industrial Storm Water Permit Number: Facility location address: City Town Village Of: ZIP Code: County: INR 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. Plan identifies individuals and their corresponding responsibilities for the facility Storm Water Pollution Prevention Team 2. 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 3. 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 4. 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 5. 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 2 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. The mapping of historical locations is only required if the historical locations have a reasonable potential for storm water exposure to historical pollutants. American LegalNet, Inc. www.FormsWorkflow.com Page 1 of 3 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 3 6. 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) Specifi