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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 m
<br />averege per response for some mirror factlities, to 110 hours as en average per response for some major facilities,
<br />with a weighted average (or major and minor facilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
<br />reviewing the collection of infortoation. Send comments regarding the burden estimate or any other aspect of
<br />Ihis collection of information, includinl cuggectiuns for reducing this burden, to Chief, Information Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affrirs, Office of Management end Budget, Washington, DC 20503.
<br />General Instructions
<br />I. If form has bun partially completed by preprinting, disregard instructions directed a[ entry of that information
<br />already preprinted.
<br />2. Enter 'Permitlee Nalrre%S1ai6ng 4AJras+ (and faciii[y namellucation, if di6erent)," "Permih Number," and
<br />"Discharge .Number" where indicated (A separate form is required for each discharge.)
<br />3. Enter dates beginning and endi.;g ",i/o,vu~rmg 1':'rind"covered by form whore indicated.
<br />4. Enter etch "Parameter' ~s specified in monitoring rcquircments of permit.
<br />5. Enter "Sun;ple Afeaeuremenr" dun `vr each parameter under "Q!rnnriR" and "Quality" in units. specified in permit.
<br />"Average" is norma!h atahmetic a+P. ~t=.. (;cometric a+• rage for hacterial parameters) of all sample measurements
<br />for each oatamctcr obtained d;~Gng ".fon:mrbrg Pcriud', "Alnnnuur," and "A4inimum" are normally extreme high
<br />and low measuremems obtained dunnp "Slornturing ..^:riud." (Nate to municipas with secondary treatment
<br />requirement: Emcr 30~1ay av;.ragc of simple meacurem:nu nnd:r "Avcruge," and enter maximum 7-day average
<br />of sample measurements obained during monitoring, perod under ".A4azunum.
<br />6. Enter "Permit Reguirenrent" for each puamcter under "~ivontity" and "Quality" as specified in permit.
<br />7. Under "No Ez" enter number of sample meazurmenis during monitoring, period that exceed tnauimum (and/or
<br />minimum or 7-day average as appropri rtr.) permit requirement for each parameter. If none, enter "0".
<br />8. Enter "Frequenct~ oJ,;naly:is" both :s ".4amp1,~ rtleasunnenr" (actual frequency of sampling and analysis used
<br />during monitoring period) and az "Pc-n,ir kequ:remenr" specified in pern,i[. (e.g., Elver "Copt," for continuotu
<br />monitoring, "/%7" far ene day p.r creek "! JO" for one day per month, "1/90" for one day per quarter, etc.)
<br />4. Enter "Sample Ttpe" hoth as "Snr,ml- A;casuremenP' (actual sample h'pe used during monitoring period) and az
<br />"Permit Requirement," (e ,., EahY 'Grab" Cor individual sample, "24NC" for 2a-hour composite, "N.A" for
<br />conunnous monitoring, etcJ
<br />i0. Where violations e° ;~.ra:il requi: ~t.~c rts ate r~C•-: c?, atmch a .`.-:ef crp;:.nation to describe cause and corrcelive
<br />actiors taken, and reference each violation by datr.
<br />! 1. if "no discharge" o:curs during me .ito icg period, enter "A'o Discharge" across form in place of data entry.
<br />12. Enter "Namer!'iUe ojPrinc+Fe! £xccu.n •° Oi7cer" with "Signnture of Pnncipal F_YCCUtive Officer ojAu(horized
<br />Agenf," "Telephone .Number ° a_-td 'Nate' at bottom of form.
<br />13. Mail signed Report to 08ice(s) w datets) specified in permit Re:a:n copy for your records.
<br />14. Mute detailed inswcuors for use of thts Discharge.4fon~toring Report (Db'R) form may be obtained from 06ice(s)
<br />specified in permit.
<br />LLeg~al Notice
<br />Phis report is required by :aw (33 U.:i.C. 1118; dJ :.F.R. !''5.27). Fa•;ure to r:port or failure to report truthfully can
<br />result in civil penalties not tc exceed t i v Oi>(, per day +.t violation; or in c, ~tninul penalties not to exceed 525.000 per day
<br />of violation, or by imprisonment for not min than one year, o- by both.
<br />EPA Aorm 3320-1 (Rev. OS-9S)
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