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Paperwork Reduction Act Notice
<br />Public reporting burden for this collection of information is estimated to vary from a range of 10 hours as an
<br />average per response for some minor facilities, to 110 hours as an average per response for some major
<br />facilities, with a weighted average for major and minor facilities of 18 hours per response, including time for
<br />reviewing instructions, seazching existing data sources, gathering and maintaining the data needed, and
<br />completing and reviewing the collection of information, including suggestion for reducing this burden, to
<br />Chief, Information Policy Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, S.W.
<br />Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office of Management and
<br />Budget, Washington, DC 20503.
<br />general Instructions
<br />1. If form has been partially completed by preprinting, disregard instruction directed at entry of that information already
<br />preprinted.
<br />2. Enter "Petmtittee Name/Mailing Address (and facility name location, if different)," "Permit Number," and "Discharge
<br />Numbat" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and editing "Ivfonitorinb, Period" covered by form where indicated
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />5. enter "SaurFle rLlaasurenent"data for each pammeter under "Qnmirity"and Quality" as specified in permit. 'Averoga" is
<br />normally aritlvnetic zverage (geometric average far bacterial parameters) of all satnpie measurements for each parameter
<br />obtained dur:ng ",'i/JnltOl'lrlg Prr"lo:.f; "i;lrximm;t" and rLiininrznrt" arc normally extreme high and ]aw measwcments
<br />ob(a ned ding "i~srrits+-ing Perioc/". (Dlote to municipds with sccondaq, trcatm%nf reeuirement: Enter 3G-day avem;;e
<br />of sr.mple mcasuremants under "Average," and enter maximum 7-day a~-eragc of sample mesurcmcnls obtained dm=.rg
<br />monitoring period under "Ir',urimum.")
<br />u. Fnte~ ;^~I;:.it IL•7ai+ _•ment"for ezcn patame[ur under "Qz!~+rliq,"and "Qrality" as specified in permit.
<br />7. Urd.. "1•', L'c" en t_; u,r:nber of samp'c mcasu:amcnt d_rin~ mari!or.rg pa~od th`, a:.cecd maxin~m (ar.~cr min: - 1n
<br />or 7-;; :y avc~agc as appropriate) permit reuui:cmwl Cur each parameter. l i none, enter "0".
<br />v. Ln'~.r "F,t;u:t,_y /y`A;ul}•sis" bath as "S •r.lE !_ ;.;= „~re+,:~.~;" (actual ircquency of sa~nplin,-; r,nd analysis used di ril,~~
<br />conitcrivg period) alid as "F~ri~."i 12.'.jlliPZ,+IJrI!"SPCC!lIC`1 ~t: :zr:ri:. (c.~. cGLer "~Ur?,"fOrcon-inuons monitoring, "I/7"
<br />Cor one dcy p,;r r~~ee~, "1/30" for one c:ay par month, "1/90" for one day per qua,-ter, etc.)
<br />9. :=.ntu "Sar,~fle T Ts" troth as 'S_--;ip1a i~~Lasu+':rnrn!" (actual s~ rp'e Type used disco monitorng period) and as "P,:rrait
<br />fe;uirzrn"u," (c.g. L-nter "Grate" for individual sample, "14HC" :or 24-how composite, "N/A" for continlous
<br />monitoring, etc.)
<br />10. ~'rle+e vitiations o: petm~i requirements ere tepolted, coach a S.ief c::plzna[ion :o dcs_ri;rc cause and corrective actions
<br />to be taken, and reference each violation by date.
<br />11. li ":ro discharge" occur during monitoring period, enler'T'o Discharge" ac,ws foam in place of data c. try.
<br />12. Enter "NmaJTitle aj Ft'inciFa! E,re.utive Qu'i_er" vrilh 'Sign~z;,+:• Gj Prin_it al C':e_-r!tiv~• Offe,:er oj` Au!ltorced
<br />Agent, ""TeleFlrate Number, "and "Gatti" at bottom of form.
<br />13. :via:'. signed Zepori to C+Tce(s) by date(s) specified in permit. P.etain copy for you records.
<br />14. )4e-~ de:~i'ed instn!ciions for use of this Discharb~a i/ionito~inb 2f.ort (D.~I12~ fort may be obtained Gum CCfce(s)
<br />speci Seri in permit.
<br />}~~~a~ ~~®~li~°~
<br />This repot is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure to nepart truthfully can result in
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation,
<br />or by imprisonment for not more than one year, or both.
<br />EPA Form 3320-1 (Rev. 03/99)
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