Alaska Msgp Annual Reporting Form
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6For Agency Use
Permit Tracking #: ___________________
Alaska Department of Environmental Conservation
MSGP Annual Reporting Form
Section I. General Information
Facility Name
APDES Permit Tracking Number
Facility Physical Address
Street
City
State
Zip Code
Alaska
Contact Person
Title
Phone
Email
Lead Inspector’s Name
Additional Inspector’s Name
Additional Inspector’s Name
Inspection Date
Section II. General Inspection Findings
1. As part of this comprehensive site inspection, did you inspect all potential pollutant
☐
☐
Yes
No
sources, including areas where industrial activity may be exposed to storm water?
If NO, describe why not:
Note: Complete Section III of this form for each industrial activity area inspected and included in your SWPPP or as newly defined, in Section II
parts 2 and 3 below, where pollutants may be exposed to storm water.
2. Did this inspection identify any storm water or non-storm water outfalls not previously
☐
☐
Yes
No
identified in your SWPPP?
If YES, for each location, describe the sources of those storm water and non-storm water discharges and any associated control
measures in place:
Page 1 of 6
MSGP Annual Report (Jan 2015)
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