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Part F: Required Monitoring (Indicate if the following monitoring is required at the <br /> permitted facility. Refer to the facility's permit certification for information on YES NO <br /> required monitoring.) <br /> Visual Monitoring (Part 1.1.1) (If any of the characteristics in Part 1.1.1.b are <br /> observed, attach a summary) <br /> Benchmark Monitoring (Part 1.1.2) <br /> Water Quality Standards Monitoring (Part 1.1.3) El <br /> Additional Monitoring Required by Division (Part 1.1.4) <br /> Part G: Corrective Actions (Indicate whether any of the following conditions YES NO <br /> occurred at the permitted facility.) <br /> An unauthorized release or discharge observed (e.g., spill, leak, discharge of ❑ ❑ <br /> non-stormwater not authorized under COG500000 or another permit); <br /> Facility control measures are not stringent enough for the discharge to meet ❑ ❑ <br /> applicable water quality standards; <br /> Modifications to the facility control measures are necessary to meet the practice- ❑ ❑ <br /> based effluent limits in this permit; <br /> The permittee finds in a facility inspection, that facility control measures are ❑ ❑ <br /> not properly selected, designed, installed, operated or maintained. <br /> Construction or a change in design, operation, or maintenance at the facility <br /> significantly changes the nature of pollutants discharged in stormwater from the ❑ <br /> facility, or significantly increases the quantity of pollutants discharged; <br /> The average of quarterly sampling results as described in Part 1.1.2.e of this El <br /> permit exceeds an applicable benchmark. <br /> If the answer to any of the above is "YES," provide a description of the conditions that met the <br /> riterion/criteria and describe the corrective action(s) taken (attach additional pages as needed): <br /> Part H: 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 <br /> in 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 /> or 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 <br /> fine and imprisonment for knowing violations." <br /> Name: Title: <br /> Signature: Date signed: <br /> 01/2018 <br />