Form 605-006 - Annual Comprehensive Site Compliance Evaluation Report printable pdf download

See Page 4 for Instructions

DEQ

Oklahoma Department of Environmental Quality

FORM

Annual Comprehensive Site Compliance Evaluation Report

605-006

for Industrial Facilities (ACSCER)

Sept. 5, 2011

Submission of this Comprehensive Site Compliance Evaluation Report, Part B, provides notice that the party

identified in Section I of this form is not required to conduct Benchmark Monitoring for storm water discharges

associated with industrial activities under the OPDES program. This Annual Comprehensive Site Compliance

Evaluation Report is required for all authorized industrial facilities.

All Requested Information Must Be Provided On This Form (Part A) and the ACSCER Form (Part B).

See Instructions On Page 4 of The Form.

Section I.

OPDES Permit Authorization Number:

Section II. Facility Operator Information

Name

Phone

: ______________________________________________

:_________________________________

Address

:______________________________________________________________________________________

City

County:_____________________ Zip Code

: __________________________________

:__________________

Section III. Facility Location

Name

Phone

:_____________________________________________________

:____________________________

Address

: ______________________________________________________________________________________

City:

County

_________________________ Zip Code

_________________________________

:_______________

Latitude: ____________________________

Longitude

:___________________________

Section IV. Certification

I certify under penalty of law that I have read and understand the requirements for filing this Comprehensive Site

Compliance Evaluation Report, which is to be filed by March 1

of each year beginning in 2012.

This report is also to be retained as part of the SWP3 for at least three (3) years from the date permit coverage

expires or is terminated and will be made available to any State or Federal Inspector visiting this facility. All records

of actions taken in accordance with 4.10 of this permit as part of the Storm Water Pollution Prevention Plan will be

retained for at least three (3) years from the date permit coverage expires or is terminated. 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

upon my inquiry of the person or persons who manage the system, or those persons directly involved in gathering the

information, the information submitted is to the best of my knowledge and belief true, accurate, and complete. I am

aware there are significant penalties for submitting false information, including the possibility of fine and

imprisonment for knowing violations.

Print Name: ________________________________________________

Date:_________________________

Signature:__________________________________________________

Title:_________________________

Form 605-006 - Annual Comprehensive Site Compliance Evaluation Report

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