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800 South Victoria Avenue Ventura, CA 93009-1600805-654-2018Monday – Friday 8:00a.m. - 5:00p.m.

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Ventura County Public Works Agency

The official website of the Ventura County Public Works Agency.

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Storm Water Treatment Facility Maintenance Record Verification Form

STORMWATER TREATMENT FACILITY MAINTENANCE RECORD VERIFICATION FORM

Property Address

Street Address of Property Address Line 2 City State ZIP Code

Assessor's Parcel Number (APN)

Responsible Party (Owner / HOA) as applicable(Required)

Name

Street Address Address Line 2 City State ZIP Code

Responsible Party (Owner / HOA) Email

Type of Storm Water Treatment System on your property:

Bioretention (with underdrain)

Bioretention (without underdrain)

Cartridge Media Filter

Catch Basin Insert

Constructed Wetland

Dry Extended Detention Basin

Drywell

Green Roof

Infiltration Basin/ Trench

Permeable Pavement

Planter Box

Sand Filter

Vegetated Swale/ Filter Strip

Wet Detention Basin

Proprietary Treatment Device

Proprietary Treatment Device Name

Current Condition of Storm Water Treatment System (Check all that apply)

Accumulation of trash and/or debris

Signs of erosion and/or exposed dirt

Pipes or risers coming into BMP are damaged (e.g., cracked)

Overflows (even during small rain storms -possibly clogged)

Overgrown or unhealthy vegetation

Excessive algae

Odors and/or standing water(water should drain from BMP within 48 hours)

Evidence of animal burrows

Signs of vandalism

None of the above

Maintenance Performed Over the Past Year

Type of Service Performed (check [] below as applicable to your device) Note: Not all maintenance tasks will apply to your device. Recommended inspection and maintenance for most BMPs is semiannually, after each significant storm, or more frequently, if needed.

Manufacturer recommended maintenance performed

Remove litter & debris as required

Repair erosion

Reseed and/or replant to damaged landscaped areas as needed

Clean/repair inlet rip rap and pilot channels

Clean/repair outlet to prevent/eliminate clogging

Remove sediment when accumulation reach 25% of original design depth

Remove accumulated sediment or tree/shrub growth that may obstruct flow through device

Replace filter media (if applicable)

Inspect perimeter fencing and repair as necessary

Repairs to device needed

Other Maintenance Performed

Device is clean and does not need service at this time

Manufacturer recommended maintenance performed

Please list manufacturer Device Model

Repairs to device needed

Please describe the repairs needed

Date repair completed or scheduled for completion

MM slash DD slash YYYY

Other Maintenance Performed

Please Describe the maintenance that was performed

Date of Owner's / HOA's Inspection

MM slash DD slash YYYY

Date of Maintenance Performed

MM slash DD slash YYYY

Acknowledgement(Required)

I herby certify that the above submitted is correct to the best of my knowledge.