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COR900000 Annual Report Form Page 2 of 2 <br />Part F: Corrective Actions — indicate whether any of the following conditions occurred at the permitted <br />Yes <br />No <br />facility: <br />- An unauthorized release or discharge observed (e.g., spill, leak, discharge of non - stormwater not <br />authorized under COR900000 or another permit); <br />El- <br />- A discharge violates a numeric effluent limit; <br />FO <br />LZU <br />Facility control measures are not stringent enough for the discharge to meet applicable water quality <br />standards; <br />- Modifications to the facility control measures are necessary to meet the practice -based effluent limits in <br />permit; <br />El <br />LOW <br />- The permittee finds in a facility inspection, that facility control measures are not properly selected, <br />designed, <br />El <br />�j <br />installed, operated or maintained. <br />IVN <br />- Construction or a change in design, operation, or maintenance at the facility significantly changes the <br />of pollutants discharged in stormwater from the facility, or significantly increases the quantity of <br />El <br />pollutants discharged; <br />- The average of quarterly sampling results as described in Part 1.1.2.e of this permit exceeds an <br />F-1 <br />ICI <br />�cl <br />applicable benchmark. <br />If the answer to any of the above questions is "Yes ", provide a description of the conditions that met the criterion /criteria <br />and describe the corrective action(s) taken" (attach additional pages as needed): <br />Part G: Required Certification Signature (Reg 61.4(1)(h)] <br />"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br />accordance with a system designed to assure that qualified personnel properly gather and evaluate the Information <br />submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible <br />for gathering the information, the information submitted is to the best of my knowledge and belief, true, accurate and <br />complete. I am aware that there are significant penalties for submitting false information, Including the possibility of fine <br />and imprisonment for knowing violations." <br />Name: <br />Title: <br />Signature: <br />Date Signed: <br />Submit Annual Report form (ORIGINAL ONLY — COPIES, PDF, FAXES, EMAILS ARE NOT ACCEPTED) by March 31 to <br />the following address: <br />Attn Annual Report <br />Colorado Dept of Public Health and Environment <br />Water Quality Control Division <br />4300 Cherry Creek Dr South WQCD P -62 <br />Denver CO 8024E <br />Form date. November 2013 <br />