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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 pet 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 />I. If form has been prrtiatly completed by preprinting, disregard instruction directed at entry of that information already
<br />preprinted.
<br />2. Enter "Pernittee Name/Moiling Address (and facility name/]ocation, if different)," "Permit Number;' and "Gischarge
<br />Number" where ins leafed. (A separate form is required for each dischazge.)
<br />3. Enter dates beginning and editing "Monitoring Period"covered by form where indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />5. Lnicr "Sample Ideasm-zr,7ad"data for each pansne!cr under "Qr~amiry" and Quality" as specified in permit. "Avzraee" is
<br />normally arithmetic average (geometric average Fur bacterial parameters) of all sample measurements for each par refer
<br />obtained during "i~f%niforing ,°eriod"; "i.Lixinnun" a[il Ibftnir„unr" are normally c:,~nne high and lo~.v measu.r.~wu
<br />cbtaired during ":~-:c.nir,.i;rg Fzrio.t". (?]cte to munici,~als w,ilh seconday trea,m_ it reruSrement: L-ntr~ 30-day averag,;
<br />of ss r;'e mcrsuremen~s under "Av=rags,"and cater rnz;:imum 7-i::y woragc of sample measucmcats obtaine9 during
<br />monitoring period raider 'hYiaximum.")
<br />6. L•r.rr ",°zr,,r%I Rr7::ir~nwn!"for eacS parameterundcr "Qa~~ntih~"and "Qr.rolity"as sp~cifed io permit.
<br />7. Under "rVo Cs" co..: nuauer o: sample rr:csaurmw, d•i:yg :acaitorag period Lhat ac,:cd maximum (andror mi~~.'~num
<br />or 7-day aacruge as appropriafc) permit requirement fur cats parameter.:: none, enter "0".
<br />8. ~,:.cr "Frr;u ~,r_~ „~`Aa3lysis" both as "S.urFla ;.f~ cnr,z,n~nt" (actual frequency of sempling and cnalysis ~~sed du]I~
<br />rnc~itoring pcr.od) and as "Per,nit 2wirane,n"specified in p_-.ni . (c.;...°.mc; "Con!,"for cori`nuous monitoring, '7/7"
<br />for or,c dzy per k~cc!:, "//30"lot one day per month, "1/90" for one day per quarter, etc.)
<br />9. °.r'et ",;a.:ry-le TyFa"both as "S_,np/s IV LJS!J'Cd12Ri" (actual sample iyy^_ use3 durng monirorng period) and as "P~;;,,ir
<br />Reyuira,-,rear," (c.g. Er'sr "tarot" fcr individuzl sample, "14HC" for 2?-hour composite, "\I/A" for contieuous
<br />monitoring, etc.)
<br />10. C.'here ~:~ioir-liens of pe,rrrit requirements are reported, attach a brief explana:icn io describe cause and corrective uciio~s
<br />to be taken, and rei'erence each violation by date.
<br />] 1. ]i "no discharge" occurs duuing monitoring period, enter "i4o Discharge" across forIIi in place o: data entry.
<br />12. ante: "A'ane/77tk of Aineipal Esrcwtive ~~~,•" v.~ith "Sib-~tature of PrraciF-rl EXZT!tiVG' GfJi;:er cj Autricrized
<br />Agent, ""TzleFhone Number,"and 'Datz" at bottom of form.
<br />13. ir;ail signed Report to Office(s) by date(s) specified in permit. Retain copy for your records.
<br />' ~. i ion detailed insmrcdons for use of This Discharge Monitoring Rpor! (I?.1~ form may be obtained from Office(s)
<br />specified in permit.
<br />Legal Notice
<br />This report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure to report truthfully can result in
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to excced $25,000 per day of violation,
<br />or by imprisonment for not mote than one yeaz, or both.
<br />EPA Fotm 3320-1(12ev. 03/99)
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