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Storm Event Data Form Appendix I
Visual Monitoring Form
Storm Event Data Fonn
4 EW
RK
ATE
Department of
Environmental
Conservation
for SPDES MS4 General Pennit,
GP-0-24-001
Do not SUDfn!l ltlls 101m fo the Department keep l nl6 tom, Wll!I tile munk:tpa1 taell!ty'&, S\V?PP and In tne MS:1 OperatOf'& SWMP Platt
Permit N'Jm!>er:
HI y I RI 2 0 A
I I I
Fac11rfy ttame:
CCll'ltaCC ~ 1Nam~
eoniact Last Name:
Coot.let P"°11e:
COOtJQEmalt
S10ffll Event Oai e-;
Si Offl'I DIRllort (In 00Ut6):
Rafntall Measurement trom Stotlll Event {In 1ncn=6):
I
Oa:;e 01 l ast MUSUratlle storm E\'Mt:
I
OtGtfoB Be!ween Storm E~en.1Sampled .vie End DC' Prevtoo, Mea,1.-ao!e S1orm l'Jfl hoin):
I
Cen ification
I eM!..'")' uo0ier penalty oruw :nat !his aocumfflt a.10 all attad'lmerc, •we prepared unaer my a1reet1on or $.UpeM6t<IO 1n aecortbnce wetha
.&)'$:an deSlg:'led to assure tte.tt qw'.lr.ed pasonn-el prol)MY ga!tlff ano:evaiu.r.e 1he-l(lrotma110n w orn~CI. 6ase<1 on my Inquiry or me
p,enon or pe,&0~ 'A1lo manage tile &)1,'tem, Of ~ person4 dk"eeuy rK ponslble ror gatner1n,g me 1nrorma11on., fne 1ntorma11on , imm1te<1
$, to tne bKtor rny t r,owie~:;e and oella-t ~ruer accurate-, and oompie:er 1am aware 1.hat mere a.re &rgl'l."lea<'l1pa,allles t0fst.t>mltt1n9 false
J1rormatron, 1n::1001ng?he l)05$!bHttyoHlne ano 1mpmonmfflt ror 1t00Mt19 vf,o1a110ns.
Fa::tt, 0,..-.WAr,U-,.,.!~ 11\dOfJ, ~ s;id•C,,.•-• ._...,._~,-~u,.,..-j
,,_ I I
.at1•• 1Jr11
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