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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 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 IS 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 information. Send commons regarding the burden estimate or any other aspect of
<br />this collection of information, urcluding suggestions for reducing this burden, to Chief, lnfotanation Policy
<br />Branch, PM-223, U.S. Em•ironmental Protection Agency, 401 M Street, SW Was6mg[on, DC 2b4b0; and to the
<br />Office of Information and R.gulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form bas been partial'.y completed by preprinting, disregard instructions directed at entry of [bat information
<br />already preprinted.
<br />2. Enter "Permittee 1'nnrcalnr/vrg .lddres.c (and facility nameJlocauon, if different)," "Permit ,Vwnber," and
<br />'l~ischnrgt :1'urnher" ~sh: re mdicatc,d. (A separate Corm is required for each discharge.)
<br />3. Enter dates beginning and ending " 1 f~rniinrinR Prricd"covered by form ~~ he: c indicated.
<br />4. Enter each "Pnrcmrtrr" ; s sperdied in manrtoring requirements ofpermit.
<br />5. Enter "Sample,llroavrr~, r7" ',.;~ for each parmncter under "OuantiN" and "QunliR" in units specified in permit.
<br />';?vernge" is nornra!h a-ni,meuc .rverage (gcomc!ric average (or bacterial parameters) of all sample measurements
<br />for each pammctcr obtit,tcd d ~nr,g "lfunnurir:g 1'cnod'; ",1farunum" and '1/irrimmn" arc normally extreme high
<br />and lore measurcment~ ;,bi:.i+ rd dunng "!, f,» utorurg Period " (Nato to r„unicipals with secondary treatmem
<br />regwrement: Enter 7o-d.n a~~crarc of sample measurements under ",tvrrr. , ," and enter maximum 7-0ay average
<br />of sample measurements ~~bLtmcd during monitoring period under ".1larununr. "~
<br />6. Enter "Peron! Requireme~u" io each parm;ct. ~ undo "Ounnrirv" and "Quulu~" :~ Specified in permit.
<br />7. Under "Vo Ex" enter m mbcr ~f vvnple nrea;urments during monitoring period that exceed maximum (andlor
<br />minimum or'-day acera e ac appropnate) permit requirement for each pammder. If none, enter "0".
<br />8. Enter "Frequencs• .,j .Ir,v/iris' both as ".`'nntl;'.. IlerzaurmenP' (actual Gequcnc}' of sampling and analysis used
<br />during monitoring pcnoa) oar ;~~ 'Termer N..•quiremnu" specified m pcnnrt. (e.g., Enter "Corr," for continuous
<br />monitoring, "l. T' for one da}' p•-r ~~eck, "J 30" for one da}' per month, "1,90" for one day per quarter, etc.)
<br />9. Enter "S'amp(e 7vpe" both us ".Sample ,[Jeusurenrenr' (actual sample [}pe used during monitoring period) and as
<br />"Permrt Requirement," (e. g., Enlcr "(irah" for individual sample, "?aH~ "' for 24-hour composite, ".-V.!4" for
<br />continuous monitoring, etc.)
<br />10. Where violations of pernut requirements arc reported, attach a brit( explat+ation to describe cause and corrective
<br />actions taken, and reference each ciolauon b}' date.
<br />l 1. U "tto discharge" occurs e.uring monitoring period, enter "No Discharge" across form in place of data entry.
<br />l2. Emer "Name.'Title of Princrpol Executrve Officer" with "Signa(vre of Principe! Executive Officer ojAuthorized
<br />Agent," "Telephone N'uml~er," and "Dale" at bottom of form.
<br />13. Mail signed Report to ONice(s) by date(s) specified in perntit. Retain copy for your records.
<br />14. More detailed instruction:; for use of this Discharge Aloniroring Report (DtifRJ Corm may be obtained from Office(s)
<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 />EP'A Form 1120-1 (Rev. 08-95)
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