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Paperwork Deduction Act Notice <br />Public repcrriing burden for This collection of information is estimated to vary from a range of 10 hours as as <br />average per response for some minor facilitiese, to 110 hours as an average per response for some major facilities, <br />with a weighted average for major and minor facilities of 16 hours per response, including time for reviewing <br />instructions, searching existing data sources, gathering and maintaining [be data needed, and completing and <br />reviewing the collection of information. Send comments regarding the burden estimate or any other aspect cf <br />this collection of information, including suggestions for reducing this burden, to Chief, Information Policy <br />Branch, PM-223, U.S. Envirotrmeotal Protection Agency, 401 M Street, SW Washington, DC 20460; and to the <br />Office of Information and Regulatory Affairs, Office of Management and Hudget, Washington, DC 20503. <br />General Instructions <br />1. If form has been paritally completed by preprinting, disregard instructions directed a[ entry of that information <br />already preprinted. <br />2. Enter "Permittee .Yame;3.lni/ing Address (ard facility namelloealion, if different)," "Permit Number," and <br />"Discharge Number" a here indicated. (A separ ate form is required for each discharge.) <br />3. Enter dates beginning and ending ;t lnnimring Period" covered by farm where indicated. <br />4. Enter each "Parameter" as specified in [monitoring regwrcments of pennil. <br />5. Enter "Sample,t4eosurement" data for each parameter tnde• "Quantity" and "Quality" in units specified in perut. <br />"Average" is normally aritlunetic avemgc (gcornetric a~eragc for bacterial parameters) of all sample measure~ncuts <br />Cor each parameter obtained durng ".llunitorin,q Yerio_I'; ".tlaximun+" and "Afioi,uum" arc normally extreme high <br />and low measurements obtained during ".t9ouitoring Period." (Note to municipals with secondary Veat[nenl <br />regwrement: Enter 3r~-dac avenge of sample measurcmenls under ",l rerage," and enter maximtuti 7~ay a~crage <br />of sample measurements obtained during monitoring period under "9/arimvm. <br />6. Enter "Permit Requirement" for each parameter under "Quantity" and "Quality" s specified in permit. <br />7. Under "Nu f::r" enter number of sample mes~urments during monitoring period that exceed maximum (and/or <br />minimum or 7-day average as appropriate) permit requirement for cacti parameter. if none, enter "0". <br />8. Enter "Frequency nj.analvsi.c" both rs ",Sample Afeaeunneet" (actual frequency of sampling and analysis wed <br />during Monitoring period) and as "Penal[ Requu•ement" specified in permit. (e. g., Enter "Cons," for continuous <br />monito¢ng, "f~7" for one day per week, "f~30" for one day pu month, "f •90" for one day per quarter, etc.) <br />9. Enter "Sample Type" both as "Sample ,tleasvr~menP' (actual sample qpe used during monitoring period) and as <br />"Permit Requirement," (e.g., enter "Grab" for indiv;dual sample, "2JIfC' for 24-hour composite, "N/A" For <br />continuous monitoring, etc.) <br />10. Where violations of pcrnut requirements are reported, attach a brief explanation to describe cause and corrective <br />actions taken, and reference each violation by date. <br />11. if "no d~scharge" occurs during monitoring period, enter "No Discharge" across form in place of data enUy. <br />l2. Enter "Name/f'itle oJPrincipal Executive O~rer" with "Signature ojPrincipnl Executive Officer ojAuthorized <br />Agent,","Telephone Number," and "Dale" at bottom of form. <br />13. Mail signed Report to 00ice(s) by date(s) specified in permit. Retain copy Cor your records. <br />14. More detailed instructions for use of this Discharge Monitoring Report (DMRJ form may be obtained from Off cats) <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 <br />result in civil penalties not to exceed 510,000 per day of violation; or in criminal penalties not to exceed 525,000 per day <br />of violation, or by imprisonment for not more than one year, or by both. <br />EPA Fatm 3330-1 (Rev. 08-95) <br />r <br />