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MAINTENANCE ACTIVITY REPORT
(Response requested within 45 days of receipt)
According to County records you are the current owner of a privately maintained stormwater management facility that had deficiencies
at the time of an inspection on . This standard Maintenance Activity Report is requested as part of the private
inspection/enforcement process. Failure to complete this form in a timely manner could result in a non-compliance status which could
lead to enforcement activities.
Complete this form legibly in ink and mail or email to the following address within 45 days of receipt.
Please reference your Site ID and Facility ID in all correspondence
Attn: Visual Condition Assessment Program
Department of Public Works and Environmental Services
Maintenance and Stormwater Management Division
10635 West Drive
Fairfax, Virginia 22030
TEL: 703-877-2800
Email: DPWES-MSMD-Inspections@fairfaxcounty.gov
Facility Information (as shown on plan of record):
Project:
Plan No:
Location:
Tax Map:
Site ID / Facility ID:
Watershed:
Ownership and Contact Information
I, ________________________, hereby certify that the statements above are true to the best of my knowledge.
Printed Name
Signature (Owner or Owner’s Agent) Title Date
Description of Work Completed
Attach any invoices, photos or other information relative to maintenance performed or planned
Date
Completed
Cost
See other side for additional space.
Current Owner:
Name:
Company:
Address:
Phone:
Fax:
Email:
Owner’s Agent for Maintenance:
Name:
Company:
Address:
Phone:
Fax:
Email:
Legislation/Regulations/Permitting/Guidelines:
• Fairfax County Codified Ordinances – Chapters 104, 112, 118 & 124
• Fairfax County Public Facilities Manual (PFM), Chapter 6: Storm Drainage
• Virginia Stormwater Management Program (VSMP) (§9VAC25-870)
• Virginia Chesapeake Bay Preservation Act (§9VAC25-830)
• Federal Clean Water Act/Section 402-(P) enabling the National Pollution Discharge Elimination System under which Fairfax County is
required to meet Federal mandates as required by the Municipal Separate Storm Sewer System (MS4) Permit #: VA0088587