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~~~erwork 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, searching 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; aad to the Office of Information and Regulatory Affairs, Office of Management and
<br />Budget, Washington, DC 20503.
<br />general Inst~°nctions
<br />1. If form has been partially completed by preprinting, disregazd instruction drrected at entry of that information already
<br />preprinted.
<br />2. Enter "Pernrittea Name/Mailing Address (and facility name location, if different);' "Permit Number," and "Duc/rarge
<br />Numhzr" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and editing "Monitoring Period" covered by form where indicated.
<br />4. Enter each "Parome[zr" as specified in monitoring requirements of permit.
<br />5. Enter 'SamFl ~ Mzlsurzment"data for each parameter under "Quantity" and Qrrali0~" as specified in permit. 'Average" is
<br />normally arithmetic average (geometric average for bacterial parameters) of all sample measurements for each pa•amc[cr
<br />obtained durng ",19,ni[~rirrg Periol"; '7~Isrinuurr" and ,bfininrrnrr" ase normally extreme high and loty mcaswemcnts
<br />obtained during "di:nil:ring Period". (A'ote to municipals with securdap~ treatment requirement: Hnte- 30~ay average
<br />of sample measurement; under "Avzragz," anc entx m~rimum 7-day average of sample measuements obtained du; ,rg
<br />monitoring period under 'Maxinrurr.")
<br />u. L-nr.., 'Fesrrir /iec;^.rir: mzn!".`or each paran'~cfer ur.uri "~r..!„li1;~"and "Qr!alir)~"as specified in pormit.
<br />7. UrJ_ ",`.'~ F.:" eni~-number of sample ~-ca: r;ranc _ G.rring moniton,~g pc,iod thy; e::ceed maeim.~m (and'or mini.T.m
<br />o- i-uay zverag_ as appropriate) permit requircmc,[ for each paramatc-. If none, enter "0".
<br />3. L-nb_r "Fr_~rur:_y ry'.".s~ry:.i,"botlr a "S~,;rflz i.i~ ~sr•:_;,: -; "(cc[ual i~egvcncy of sampling and analysis used during
<br />monRc.ing period) a,rd as "!'en,tit Rz?ui,Y,nznt" spec~ficl :n ,._ari:. (c.g.:?ntcr "Cunt,"for continuous monitoring, "I/7"
<br />for ere d ry pe; a~ec's, "1/30" for cne day per .-ron~, "1/40" far ouc day per qua.ier, etc.)
<br />9. ..°.nte: ^Sar;,r!r TjT~"bulb as "Sa;uf le ,:oeasnrzr:_r " (.~c:uc' s~np'e Type used during monitoring period) and as "Penait
<br />Fcaq;eirernznt," (u.g. L-nter "Groh" for indivi2uel sa~p!c, '24UC" fo- 2'i-ho;a ccmposiie, 'N/A" for contin~oas
<br />monitoring, etc.)
<br />]0, Yl'ha: e v:olnticns of permit requirements r:~ r e,:ortc~, ~[~rc:r a ~:'e` c~pl~aation to deacribe cause and corrective an, ions
<br />to be lateen, and reference each violation by date.
<br />1 I, if"ro discharge" occurs during monitoring p;;riod, ents "~'u Disch~be" across form in place o~ data eni-y.
<br />12. Enter "Nor,rz/Title of Principal E.czcrrtive Gffixr" criih "Sign.,rrrr of Prbrar~ ,l E:z,utivz Officer of Arrthorczd
<br />Ag.nt, ""Te%plrare NunrFzr} "and 'Dare"a[ bottom of form.
<br />? 3.:v;ai, signed 2epor( to Cruce(s) by date(s) spcciGed in pcrntit. 2etain copy for your records.
<br />]4. ?%or_ deuri'cd instructions nor use a this Dis_h~ras i.,'•,nitoriag R=Fo,t (DivaRl rein may be obt<incd from CTee(s)
<br />specified in permit.
<br />This repot is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure to resort truthfully can result is
<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 [Iran one yeaz, or both.
<br />EPA Form 3320-1 (Rev. 03/99)
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