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Quarterly Visual Assessment Monitoring Form – Pueblo, CO
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Step
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of
3
33%
Complete One Form Per Outfall
Date
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MM slash DD slash YYYY
Inspected By:
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First
Last
Title
Discharge/Outfall Applicability
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Note: If a facility does not discharge or have designated outfalls, a stormwater monitoring inspection shall be conducted to verify the absence of discharge.
This facility does not discharge or have designated outfalls.
This facility has outfalls and/or discharge may occur.
Assessment Instructions
Visual assessments shall be made of samples collected in a clean, clear glass or plastic container in a well-lit area within the first 30 minutes (or as soon thereafter as practical) of when the runoff begins discharging from the facility. All samples shall be collected from a storm event that produces measurable discharge and that occurs at least 72 hours from the previously measurable storm event. The 72-hour storm interval is waived when the preceding measurable storm did not yield a measurable discharge, or if the facility documents that less than a 72-hour interval is representative for local storm events during the sampling period. Samples shall be discarded following evaluation.
Visual Assessment Conditions
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Check all that apply
Stormwater monitoring inspection conducted in lieu of visual assessment; no discharge from the facility was identified.
No storm event resulted in measurable discharge during the quarter.
No measurable discharge occurred during daylight hours during the quarter.
Adverse weather prevented sample collection and examination (explain below).
Sample collected appeared to contain contamination (explain probable sources below).
Sample was collected at least 72 hours from previously measurable event.
Sample was collected within 72 hours of previously non-measurable storm event (explain below).
Sample was collected within 72 hours of a measurable event (representative of area, explain below).
Sample was not collected within the first 30 minutes of discharge (explain below).
Explanation
Complete only if applicable.
Discharge Appearance
Outfall Name
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Provide details or enter NA
Color
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Provide details or enter NA
Odor
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Provide details or enter NA
Clarity
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Provide details or enter NA
Solids
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Floating, settled, or suspended or enter NA
Foam
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Select No if not applicable
Yes
No
Oil Sheen
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Select No if not applicable
Yes
No
Other
Certification Statement
“I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information contained therein. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information contained is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.”
Inspected By:
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First
Last
Title
Signature
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Complete a Corrective Action Form as necessary.
Store completed forms in Appendix 13.
