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103 Wilson Street <br />Page 2 O&M Inspection Report <br />V.Summary of Inspections and Maintenance: <br />Use the attached Treatment Area Inspection and Maintenance Checklist to conduct <br />inspections monthly (or as needed), identify needed maintenance, and record <br />maintenance that is conducted. <br />VI.Sediment Removal: <br />Total amount of accumulated sediment removed from the storm water treatment <br />measure(s) during the reporting period: _________ cubic yards. <br />How was sediment disposed? <br />£landfill <br />£other location on-site as described in and allowed by the maintenance <br />plan <br />£other, explain: <br />VII. Inspector Information: <br />The inspections documented in the attached Inspection and Maintenance Checklists were <br />conducted by the following inspector(s): <br />Inspector Name and Title Inspector’s Employer and Address <br />VIII. Certification: <br />I hereby certify, under penalty of perjury, that the information presented in this report and <br />attachments is true and complete: <br />Signature of Property Owner or Other Responsible Party Date <br />Type or Print Name <br />Company Name <br />Address <br />Phone number: Email: <br />7.1.D. - Page 23