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Paperwork ]Reduction Act Notice
<br />I Public repor.ing burden for [his collection of information is estimated [o vary from a range of l0 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 major and minor facilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, ga'.hering and maintaining the data needed, and completing and
<br />reviewing the collection of infot>na[iom. Send comments regarding [he burden estimate or any other aspect of
<br />this collection of information, including suggestions for reducing this burdem, [o Chief, information Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washington, DC 20460; and to fire
<br />Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed at entry of That information
<br />already preprinted.
<br />2. Enter "Permiltee .Name%blailing Address (and facility nartte/location, if different)," "Permi( A'umber," and
<br />"Discharge Number" where indicated. (A separate form is required Cor each tfischazge.)
<br />3. Enter dates beginning and ending ",tfonrtoring Period" covered by forth where indicated.
<br />4. Enter each "Pararnerer" as specified in monitoring requirements of permit.
<br />5. Enter "Sarnple,tfea.vurement" data for each pa'ameter under "Quantity" and "Qva/ihl' in units specified in Fermi[
<br />"Average" is normally arithmetic average (geometric average for bacterial parameters) of all sample measurements
<br />for each parameter obtained during ".ifonilorir,g Period'; ".tlraimum" acd ",Nimmum" arc nornutlly extreme high
<br />and low measurements obtained during ".I tonirormg Period" (Note ro municipals Hith secondary Vcatment
<br />requiremenC Enter 30~ay avcmgc of sample measurements under "Average," and enter maximum 7-day average
<br />of sample measurements obtained during monitoring period under ".~Jaxin,um.
<br />6. Enter "Permit Reyavrment" (or each parameter under "Quantity" and "Quality" as specified in permit.
<br />7. Under ".'v'n Es" toter number of sample mcasurrncnts during monitoring perod Lhat exceed maximum (and/or
<br />minimym or 7-day average as appropriate) permit requirement for each parameter If none, enter "0".
<br />8. Enter "Frequency ojAnalysis" both as "Smnple .tleawrment" (actual frequenn• of sampling and analysis usec
<br />during monitoring period) and as "Permi! Reyuirenrent" specified m permit. (e g., Enter "Copt," for continuous
<br />monitoring, "I/T' far one day per week, "l '30" for one day per monllL "/i90" for one day per quarter, etc.)
<br />9. Enter "Smnple Type" both as "Sample ,t/easvrernent" (actual sample type used during monitoring period) and as
<br />"Permit Reyuirernenl," (e.g., Enter "Grab" fx indisidual sample, "1J1/C"' for 24-hour composite, "1!rf!" for
<br />condnupus monitoring, etc.)
<br />10. Where violations of permit requirements are r:ported, attach a brief exp'anation to describe cause and corr_c:ive
<br />actions taken, and reference each violation by date.
<br />l 1. tf "no dscharge" occurs during monitoring period, curer "A'o Drscharge" across form in place of data entry.
<br />l2. Enter ".,Name~Ti!!e ojPrincrpal Executive Officer" with "Signature ojPrincipal Executive Officer ojAuthoriaed
<br />Agent,"'"Telephone Number," and "Date" a[ bo0om of form.
<br />13. Mail signed Report to Office(s) by date(s) specified in perntit. Retain copy for your records.
<br />14. More d tailed instructions for use of [his Discharge A4on!loring Report (D,L1RJ form may be obtained from Office(s)
<br />specified in permit.
<br />~, Legal Notice
<br />This report is roquired 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 ~enalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed 525,1X10 per day
<br />of violation, on by imprisonment for not more than ant: year, or by both.
<br />EPA Fotvt 3320-1 (Rev. 08-95)
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