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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)
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