Evaluator Name: _________________________________	Date:_________________________

Facility Name: ___________________________________	Facility Contact: _______________

Facility Address: _________________________________	Phone No: ____________________

Operation: ______________________________________________________________________

Proposed Inspection Frequency:____________________________________________________

Potential Pollutants

Sediment___	Nutrients___ Trash___ Metals___ Bacteria___ Oil & Grease___

Organics___ Pesticides___ Other___________

BMPs employed:

BMPs recommended:

General Stormwater Training Video

PPD and BMP Effectiveness Rating for years 2007 -2010

Potential Pollutant Discharge (PPD) 1= High Potential 2= Medium Potential 3= Low Potential

BMP’s employed Yes	No	PPD 1-3	EFFECTIVENESS RATING

Year 2007 [ ] [ ] [ ]	1 2 3 4 5
Year 2008 [ ] [ ] [ ]	1 2 3 4 5
Year 2009 [ ] [ ] [ ]	1 2 3 4 5
Year 2010 [ ] [ ] [ ]	1 2 3 4 5

EFFECTIVENESS RATING

1. No BMP’s used Stormwater Pollution likely

2. Some BMP’s used but not effective

3. Some BMP’s used and moderately effective

4. Source control BMP’s used and very effective/structural BMP’s needed

5. All necessary BMP’s used and very effective

Facility Name: ______________________

garyw

2007-02-14

City Of Grand Island