Alaska Msgp Annual Reporting Form Page 4
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6For Agency Use
Permit Tracking #: ___________________
Industrial Activity Area:
1. Brief Description:
☐
☐
2. Are any control measures in need of maintenance or repair?
Yes
No
☐
☐
3. Have any control measures failed and require replacement?
Yes
No
☐
☐
4. Are any additional/revised control measures necessary in this area?
Yes
No
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?
Yes
No
☐
☐
3. Have any control measures failed and require replacement?
Yes
No
☐
☐
4. Are any additional/revised control measures necessary in this area?
Yes
No
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.)
Page 4 of 6
MSGP Annual Report (Jan 2015)
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