Stormwater Cleaning Approval Form

STORMWATER CLEANING APPROVAL FORM

Applicant / Property Owner

Property Identification

Property Address:

Parcel / APN Number:

Contractor / Service Provider

Proposed Cleaning Work

Cleaning Location on Site:

Best Management Practices (BMPs)

Applicant shall implement the following BMPs. Check all that apply and describe details where requested.

Environmental Compliance & Disposal

All removed material and wash water must be managed and disposed of in accordance with applicable environmental laws. Applicant certifies the below:

Fees, Deposit & Payment

Permit/Inspection Fee: $ Security Deposit: $

Payment Due Date:

Late Fee / Interest:

Required Attachments (must be submitted with application)

If other attachments are provided, list and describe:

Conditions, Certifications and Indemnification

By submitting this form, Applicant certifies under penalty of perjury that the information provided is true and correct. Applicant agrees that all work will be performed in compliance with all applicable federal, state, and local environmental statutes and regulations, and in accordance with the Best Management Practices checked above. Applicant authorizes authorized representatives of the Approving Authority to inspect the site during work and to require corrective measures if BMPs are not implemented or discharges occur.

Applicant shall defend, indemnify and hold harmless the Approving Authority, its officers, agents and employees from and against any and all claims, liabilities, damages, losses and expenses (including reasonable attorneys’ fees) arising out of or resulting from the Applicant’s performance under this approval, except to the extent caused by the sole negligence or willful misconduct of the Approving Authority.

Approval granted under this form may be suspended or revoked by the Approving Authority if Applicant fails to comply with any condition of approval, fails to implement required BMPs, causes an unauthorized discharge, or otherwise creates an immediate threat to water quality or public health. Applicant agrees to correct any violation immediately upon notification and to bear all costs of cleanup, remediation, and any enforcement actions.

Approving Authority Conditions (to be completed by authority)

Required Inspection Prior to Release of Security Deposit:

Governing Law and Entire Agreement

This approval and the obligations created hereunder shall be governed by and construed in accordance with the laws of the state in which the property is located. This document constitutes the entire agreement between Applicant and the Approving Authority with respect to the subject matter herein and supersedes all prior agreements and understandings, whether written or oral, relating to the stormwater cleaning activity described herein.

Acknowledgment

Applicant acknowledges that false statements or omissions in this application may result in denial, revocation of approval, civil penalties, and criminal prosecution where applicable. Applicant agrees to maintain required insurance coverages and provide updated certificates upon request.

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