SWPPP Annual Assessment Form

The City of _______________ Stormwater Management Program Annual Site / Program Assessment

Facility:_____________________________________________________

Facility Contact: _____________________________________________

Contact Phone: ______________________________________________

YES

NO

Not Applicable
Facility’s SWPPP easily accessible in each Building?

Awareness of SWPPP by facility Personnel?

(Random survey of employees of site.)

# Employees Surveyed______________

Facility’s Emergency Response Plan easily accessible in each building?
Awareness of Emergency Response Plan by facility personnel?

(Random survey of employees on site.)

# Employees Survey ____________________
Annual Evaluation Checklist (page 2 of 2) completed?
Was any Stormwater Pollution prevention training conducted during the year?
Were non-Stormwater discharge visual observations conducted?

List Dates:
Were Stormwater discharge visual observations conducted?

List Dates:

Evaluation Notes:

______________________________________________________________________________________

Corrective Measures Recommended:

______________________________________________________________________________________

Evaluation Conducted By: _______________________________________________________________

This Completed evaluation was reviewed and completed on (Date):_____________________________

Operation Representative (signature):____________________________________________________________________________

SWPPP Annual Assessment Form

garyw

2007-03-07

City Of Grand Island