DWQ-2024-001131

Industrial Stormwater Pollution Prevention PlanTemplate
This template has been developed to assist facilities in Utah to comply with the requirements of Utah’s Multi-Sector General Permit for Stormwater Discharges Associated with Industrial
Activities (MSGP) and the requirements for specific industrial sectors (Appendix I of the Permit).
This template is not a substitute for the general permit or specific Appendix I requirements. When developing the Stormwater Pollution Prevention Plan, the permittee should ensure all
required components have been included by referencing Part VII of the MSGP and all applicable Appendix I sections.A copy of the MSGP is available at: https://deq.utah.gov/water-quality/general-multi-sector-industrial-storm-water-permit-updes-permitsUsing
the Industrial Stormwater Pollution Prevention Plan TemplateThis Template is designed for use by all facilities eligible for coverage under the MSGP. The Template is NOT tailored to
your individual industrial sector. Depending upon your industrial sector (seeAppendix I of the MSGP), you may need to address additional requirements.Complete a Stormwater Pollution
Prevention Plan before submitting your Notice of Intent (NOI) for permit coverage.Each section includes instructions and space for your facility’s specific information. You should read
the instructions for each section before you complete that section.The Template was designed so that you can add tables and additional text if necessary. To make it easier to complete,
the Template generally uses blue text where the operator is expected to enter information.Your completed Stormwater Pollution Prevention Plan should remain on site in an accessible format
and be able to be made available if requested by an inspector. A copy does not need to be submitted to the State when the NOI is submitted.
The Utah Division of Water Quality (DWQ) notes that while DWQhas made every effort to ensure the accuracy of all instructions and guidance contained in the Template, the actual obligations
of regulated industrial facilities are determined by the relevant provisions of the permit, not by the Template. In the event of a conflict between the Template and any corresponding
provision of the MSGP, the permit controls.DWQwelcomes comments on the Template at any time and will consider those comments in any future revision of this document.Storm Water Pollution
Prevention Planfor:
Insert Facility Name
Insert Facility Address
Insert City, State, Zip Code
Insert Facility Telephone Number (if applicable)Storm Water Pollution Prevention PlanContact(s):
Insert Facility Operator
Insert Name
Insert Address
Insert City, State, Zip Code
Insert Telephone Number
Insert Fax/EmailStorm Water Pollution Prevention PlanPreparation Date:
__ __/ __ __ / __ __ __ __Contents
CERTIFICATION.
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
Name:
Title:
Signature:
Date:
KEEPING PLANS CURRENT.
Date of Review
Name of Reviewer
To the best of my knowledge, this Plan is accurate and up-to-date.
Reviewer Signature
[Date]
[Reviewer Name]
Yes No
[Date]
[Reviewer Name]
Yes No
[Date]
[Reviewer Name]
Yes No
[Date]
[Reviewer Name]
Yes No
[Date]
[Reviewer Name]
Yes No
CONTENTS OF THE PLAN.
3.1Pollution Prevention Team.
Name and/or Title
Individual Responsibilities

Insert name and/or title of team member
Insert explanation of that staff person’s individual responsibilities relating to Plan.
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3.2Description of Activities at the Facility.Describe Industrial Activities Here.
3.3Site Map.
The site map for this facility can be found in Attachment 1.
3.4Summary of Potential Pollutant Sources.
Activity
Pollutant Source
Pollutant(s)
Location
BMPs
Treatment (if any)
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3.5Measures and Controls.
3.5.1Good Housekeeping.
Good Housekeeping Practices
Schedule or Convention
(i.e. weekly, when identified, as needed, etc.)
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3.5.2Preventative Maintenance.
Measures or Equipment
Requiring Routine Maintenance
Schedule or Frequency
(i.e. weekly, monthly, as needed, etc.)
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3.5.3Employee Training.
Employee training for required personnel will be conducted [Add Frequency Here (monthly, annually, etc.].
Blank Employee Training Logs can be found in Attachment 2, if needed.
3.5.4Spill Prevention and Response Procedures.
Area or Material Where
Potential Spill Could Occur
Discharge Point if a Spill Occurs
Nearest Spill Clean or Containment Control Measure
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Material Handling and Storage Procedures: [Brief description of how materials that could meet the significant spill criteria in the event of a spill, such as bulk chemical storage, will
be managed and stored.]
Facility Personnel to Contact
[Facility Contact]
Phone:
[Phone]
[Facility Contact]
Phone:
[Phone]
State Contact
Utah DWQ, 24-hour Environmental Incident Line 1,2
Phone:
[phone]
National Contact
National Response Center 2
Phone:
[phone]
1 Used oil releases exceeding 25 gallons, or smaller releases that pose a potential threat to human health or the environment.
2Where a leak, spill or other release containing a hazardous substance in an amount equal to or in excess of a reporting quantity established under either 40 CFR Part 110, 40 CFR Part
117, or 40 CFR Part 302, occurs during a 24-hour period.
Response Schedule (timeline for when response to spills should occur): [Add Response Schedule]
A list of significant spills of toxic of hazardous pollutants that have occurred at areas exposed to precipitation or that drain to a stormwater conveyance at the facility for three
years prior to submission of the NOI up to the present day are included in Attachment 3.
3.6Non-Stormwater Discharge Evaluation.
A Blank Non-Stormwater Discharge Evaluation form can be found in Attachment 4.
Explanation of why certification is not feasible, if applicable:If applicable, describe why certification is not feasible.]
3.7Inspections, Assessments, and Evaluations.
Routine
Facility Inspections
Visual Stormwater Quality Assessments
Comprehensive Site Compliance Evaluations
Inspector or Position
[Name or Position]
[Name or Position]
[Name or Position]
Other Inspector or Position
[Repeat as necessary]
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Frequency
[Quarterly, Monthly, etc.]
[Quarterly, Monthly, etc.]
[Quarterly, Monthly, etc.]
Areas, Materials, and Activities to be Inspected (see Part III and Appendix I): [Areas, Materials, and Activities]
Blank routine facility inspection forms can be found in Attachment 5. Blank visual stormwater quality assessment forms can be found in Attachment 6. Blank comprehensive site compliance
evaluation forms can be found in Attachment 7.
3.8Monitoring and Reporting.
Parameter
(see Part E of Appendix I)
Sample Location
(i.e. Outfall 001)
Benchmark/Numeric Effluent Concentration
Sample Frequency
Sample Year(s)
[Parameter (TSS, pH, etc.)]
[Outfall 001]
[100 mg/L, 0.068, etc.]

[Quarterly, Annual]
[2024, 2025, etc.]
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3.9Additional Plan Documentation.A copy of the Multi-Sector General Permit (MSGP) Authorization email assigning the UPDES permit number, and the effective date and expiration date of
coverage.A copy of this permit as a hard copy or in an easily accessible electronic format for facility personnel;A copy of any other existing UPDES permits authorizing discharges of
anything other than stormwater as a hard copy or in an easily accessible electronic format; andA copy of the electronic submittal waiver letter from the Director, if applicable.
3.10Modification Log.
Date
Modification or Correction
Reasoning for Modification
Modifier Signature 1
[Date]
[Description of Modification]
[Reason for Modification]
[Date]
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[Date]
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1 Those signing in this column is making the following certification:
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
ATTACHMENT 1: Site Map
Include a copy of your site map(s).
ATTACHMENT 2: Employee Training
Included is a blank Employee Training log and completed forms.
Employee Training Log
Date of Training
[Date]
Topic(s) of Training
[Training Topic]
Name of Person Conducting Training
[Instructor Name]
Name of Trained Employee
Signature of Trained Employee
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]

[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
[Name]
ATTACHMENT 3: Significant Spills of Toxic or Hazardous Pollutants
Include a list of all significant spills or hazardous pollutants within three years of the date of submittal of the NOI to the present day.
Significant Spills of Toxic or Hazardous Pollutants
Date of Significant Spill
Location
of the Spill
Description of Spill
Description of Clean-up
[Date]
[Location]
[Description of the Spill]
[Description of the Clean-up]
[Date]
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ATTACHMENT 4: Non-Stormwater Discharge Evaluation
Included is a blank Non-Stormwater Discharge Evaluation form and completed forms.
Non-Stormwater Discharge Evaluation
The permittee shall eliminate all non-stormwater discharges not authorized under Part I.D.2 of the MSGP. If not covered under a separate UPDES permit, wastewater, wash water, and any
other unauthorized non-stormwater shall be discharged to a sanitary sewer, in accordance with applicable industrial pretreatment requirements, or otherwise disposed of appropriately
(i.e. hauled off site to an appropriate disposal facility, allowed to evaporate, etc.). This permit does not authorize the permittee to discharge to the sanitary sewer. If the facility
does connect to the sanitary sewer, the permittee shall be responsible for obtaining the approval and/or permitting from the sanitary sewer operator prior to discharging. (MSGP Part
III.K)
Date
Identification of Authorized Non-Stormwater Discharge (see MSGP Part I.D.2.b)
Evaluation Criteria or Testing Method (visual observation, sampling, etc.)
Discharge Point for Identified
Non-Stormwater Discharge
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
Name:
Title:
Signature:
Date:
ATTACHMENT 5: Routine Facility Inspections
Included is a blank Routine Facility Inspection form and completed forms.
Routine Facility Inspection Form
Inspection Date:
Inspection Time:
Inspector Name:
Is there a discharge occurring at the facility?
If yes, what is the location of the discharge?
Yes No

Inspected Areas
The inspected area needs (include comments below):
Maintenance
Repair
Replacement
No Action
Not Applicable
Areas where materials, residues, or trash are come in contact with stormwater
Areas where activities or materials are exposed to stormwater at the facility
Areas where equipment, drums, tanks, or other containers are being stored
Areas where tracking from vehicles entering and exiting the facility occurs
Areas where soil erosion has occurred or has the potential to occur
Areas where unauthorized non-stormwater discharges may be occurring
All discharge points
All control measures installed at the facility to control stormwater
Comments on any maintenance, repairs, or replacements identified above:
Any other incidents of non-compliance with the permit:
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
Name
Title
Signature
Date
ATTACHMENT 6: Visual Stormwater Quality Assessments
Included is a blank Visual Stormwater Quality Assessments and completed forms.
Visual Stormwater Quality Assessment Form
Assessment Date:
Assessment Time:
Name of the individual(s) conducting the assessment:
Was the sample taken within the first 30 minutes of when runoff from a storm event began at the facility? (if no, explain why)
Was the assessment conducted during daylight hours and during normal operating business hours?
Yes No
If no, explain:
Yes No
Type of Stormwater Sampled
If yes, what is the location of the discharge?
Rain Snowmelt Other
Comments
Color (i.e. clear, brown, gray, etc.)
Odor (i.e. no smell, sewage, gasoline, bleach, etc.)
Clarity (i.e. clear, murky, etc.)
Floating solids at the top of the sample
Settled solids at the bottom of the sample
Suspended solids floating within the sample
Foam (i.e. none, thick, thin, etc.)
Oil sheen (i.e. no sheen, rainbow, etc.)
Any other obvious indicators of stormwater pollution
If any potential source(s) of pollutants were identified above, identify the probable source(s):
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
Name
Title
Signature
Date
ATTACHMENT 7: Comprehensive Site Compliance Evaluations
Included is a blank Comprehensive Site Compliance Evaluation form and completed forms.

Comprehensive Site Compliance Evaluation Form
Evaluation Date:
Name of the individual(s) conducting the evaluation:
The evaluation shall include at least the following:
All industrial activities taking place at the facility and all materials that are located at the facility to ensure they have been identified in the Storm Water Pollution Prevention
Plan;
The control measures that have been installed at the facility to determine if they are adequate, properly designed, and correctly implemented;
All stormwater management measures, sediment and erosion control measures, and other pollution prevention measures to ensure they are operating correctly;
The equipment needed to implement the Storm Water Pollution Prevention Plan, such as spill response equipment, to ensure it is adequate and located appropriately throughout the facility
as needed;
The Storm Water Pollution Prevention Plan to ensure it is current with existing facility operations; and
All associated documents, such as sampling results, inspection reports, and additional permit documents, to ensure they are accurate and are being maintained with the Storm Water Pollution
Prevention Plan in an accessible format.
Describe any corrections needed to be made in the Storm Water Pollution Prevention Plan in relation to changes or updates to stormwater management, sediment and erosion control, and
other pollution prevention measures?
Are there any known incidents of noncompliance with the permit?
If there were any corrections needed or known incidents of noncompliance identified above, complete these corrections before continuing this evaluation.
Is the Stormwater Pollution Prevention Plan up-to-date and current with existing facility operations?
Is the facility in compliance with the Stormwater Pollution Prevention Plan and the permit?
Yes No
Yes No
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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted 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.
Name
Title
Signature
Date
ATTACHMENT 8: Additional Plan Documents
Attach copies of all applicable documents:
A copy of the Multi-Sector General Permit (MSGP) Authorization email assigning the UPDES permit number, and the effective date and expiration date of coverage.
A copy of the permit as a hard copy or in an easily accessible electronic format for facility personnel.
If applicable, a copy of any other existing UPDES permits authorizing discharges of anything other than stormwater as a hard copy or in an easily accessible electronic format.
If applicable, a copy of the electronic submittal waiver letter from the Director (MSGP Part I.I.2)