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<br />Paperwork Reduction Act Notice
<br />Public reporting burdee for dis 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 facilities,
<br />with a weighted average for roajor and ' 'es of 4~g• hours per response, including time for reviewing
<br />instructioos, searching existing data sources, - ° pg sdirt2ining the data needed, apd cblt$)Uipg and
<br />reviewing the collection of information. Send is regarding [he burden estimate or agyiHhei. aspect of
<br />this collection of ipformation, including suggestid r ,rt;uciag this burdep;,fo Chief, information Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency,'i01 iv1 Street, SW Wj~Vhiugton, DC 20460; end to the
<br />Office of Informntioo and Regulatory firs, Office of Ivianagement end Budd Washington, DC 20503.
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<br />r~-' ~eneralInstructions
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<br />1. If form hats beep partially completed by preprinting, disye~arrd instructions directed at entry of that information
<br />already preprinted. ,~~,
<br />2. Eater 'Permtttee Nnme/M,ailing Address (and facility name/locaion, if different)," "Permit Number," and
<br />"Discharge Number" where indicated,._ii~separate form is required for each discharge.)
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<br />3. Enter dates beginning and ending 'Mluftoring Period" covered by form where indicated.
<br />4. Enter each "Parameter" az specified in monitoring requirements of permit.
<br />5. Enter "Sample Afeasuremenf :data for esch parameter under "Quantity" and "Quality" in units specified in permit.
<br />"Average" is normally aritltp?ietic average (geomdric average for bacterial parameters) of aJl sample measurements
<br />for each parameter obtairtetl during "nfonitoring Period"; "Maximum" and ".t'finimunt" are normally extreme high
<br />and low measurements obtained dung ",tfomra•ing Period." (Note [o municipals with secondary treatment
<br />requiretnenC. Enter 30-day zveragc of sample meastuemcnts unGcr "Average," and enter maximum 7-day average
<br />of sample ttieasuremcns obuuned during monitotin~ period under "nlaximum. J
<br />6. Enter "Permit Requirr•neenr' for each parameter under "Quantity" and "Quality" az specified in permit.
<br />7. Under ",Vo F~:" enter number of sample mcasunnents during monitoring ,o.°riod that exceed maximum (and/or
<br />minimum or 7~ay average az appropriate) .remit requirement for each parameter. If none, enter "0".
<br />8. Enter "Frequency ojAnalysis" both az "Sample Measurment" (actual frequency of sampling and analysis used
<br />during monitoring period) ,md az "Permit Requirement" specified in permit. (e.g., Enter "Conn" for continuous
<br />monitoring, "//7" for one dsy per week, "l/30" Cor cne day per month, "li90" for one day per quarter, etcJ
<br />9. Enter "Sample Tvpe" both as "Sample bfeasuremenr" (actual sample type used during monitoring period) and az
<br />"Permit Requirement," (e.g., Enter "Grab" for individual sample, "2JHC" for 24-ham composite, "N/A" for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements are reported, attach a brief explanation to describe cause and corrective
<br />actions taken, and reference each violation by date.
<br />I I. If "no discharge" occurs during monitoring period, enter "No Dischnrge" across form in place of data entry.
<br />12. Enter "Narne.~fille of Princ.'pa! Executive Officer" tvith "Signature ojPrincipal Executive Officer ojAuthorized
<br />Agent," "Telephone Number." and "Dale" a[ bottom of foram.
<br />13. Mail signed Report to t~ce(s) by date(s) specked in permit. Retain copy far your records.
<br />14. Mare detailed instrticions far use of this Dischnrge rLfonitoring Report (D.ifR) forth may be obtained from Office(s)
<br />specked 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 t:an
<br />result in civil penalties pot to exceed 110,000 pe: day of v.olatioo; or in criminal penalties not to exceed $25,000 par day
<br />of violation, or by imprisorunent far nut more than one year, or by both.
<br />EPA Rorpt 3j20-1 (Rxv. U8-95)
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