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rr`T'~~C:''VdCii~. ~C~iiCtBL"I] ~tC~ 1'~1.`EF"°~-^, <br />Public reporting burden for this collection of information is zstimated to vary From a range of 10 ho[ rs as an <br />average per response for some minor facifties, to 110 hours as an average per response for u.re major <br />facilities, vrith a weighted average for major and minor tarlities of Ik hours per response. including time fitt <br />revizxine instructions, searching existine data sources, gathering and mainlainirg the data nzzecd. a.td <br />completing and reviewing the collection of information. Send comments regarding the burden estimate nr an} utF~r <br />aspect of this collection of information. including suggestions for reducing this burden, to Chief, I~txmation <br />Policy Branch. PM-?'_3, U.S. Environmental Protection Agency. 301 M Street. SW, K'ashington. D(" ?t 460; aid <br />to the Off ice of Information and Regulator} Affairs, Office of S1anugzment and Budget. Washington. DC ?Od0?. <br />£~erier~i 9nst~ruet;~~s <br />I. If form has been partially completed b} prepriming, disregard instructions directed ai entry of that in(o:ma[iui <br />already preprinted. <br />?. Enter 'Permittee Name/,tfailing .4dJress Omd facility name] location. i( ddlerenU.~' "Permit Vumbcr.- atd <br />"Discharge Number' where indicaed. (A separate form is required for each dischnrge.) <br />3. Enter dates beginning and ending "Monitoring Period' covered by form vv hart indicated <br />4. Enter each "Parameter" as specified in monitoring requirements of pt rots t. <br />5 Enter 'Sample Measurement" data for each parameter under "Quanrir7 "aid 'Qualir)'' i t umo specs) std in p.nre . <br />".gverage" is normally arithmetic average lgeomet~ic average fnr bacterial paramelenl ul all sample reasu-c noels <br />fur each parameer oblaintd during "Monitoring Period"; 'hlarinurm` and 'hlininnrnr~' are nonndll} ev~remt higt <br />and line measurements obtained dunng -M11onifonng Partied' (Note to municipals v.ith seconds ry tre6tmenl <br />requirement: Enter 30-day average of sample measurements under 'Avrrrge." and em:r maximum ~-day a~era,gs <br />of sample measu rcments obtained dunng monitoring period under "M14arimum:') <br />6. Enter "Permit Requirement" Ibr each parameter under "Quantity- and "Qualit r" as sperfiad in permit. <br />7. Under `No Ea" enter number of ,ample measurements during monitorine period that tvcced m,ni.~uun ~and,:rr <br />minimum or ~-dJY average as appropriate) permit requirement for each parameter. If nor:. enter "0". <br />S. Enter 'Frequency of Analysis' both as "Santp/e Measurement" (actual frequency of sampling and nnalysie used <br />during moo oaring period) and xs "'Parrnir RequiremenC' specified in permit. (e.e.. Fnitr "C'ont." liar cunlinuoa, <br />monitoring. "1/7" fur one day per week, `1,'.70" toi one day per month. "l,'9p" for one day per quarter, ctc.l <br />Q. Eider '"Sample Tfpr" both as 'S:unple Aeasurement" (actual sample type teed during monitorine period) ~tJ a, <br />"Permit Requirement' (e.g.. Enter "G r;+h" for individual sample, "2dHC"' for 33-hour composite, "'.V'4" tar con- <br />tinuous monitorine, etc.) <br />!U. Where violations of permit requirements ;iro reported, attach a brie) eaplanution to describe cause and correcti.t <br />actions taken. and reference each violation b} d:ue. <br />I I. If "no discharge' occurs during monitoring ~criod. enter "No Discharge" across form in pace of data :ntr.:. <br />I?. Enter "Name/Title of Principal Errcu(ire Ollicrr" with "Signature nl Principal E[ecmire O(licer n( .4uthnrietd <br />Agent, ~' "Telephone Numher," and `Dare- at bottom of form. <br />13. Mail signed Report to Ofl ice(,) b} date(s) specif led in permit. Retain copy for your records <br />14. Mort detailed instructions for use oY thi. Dischm;ya Mumuning Report (DMR) form nay be obtu~ned from OI- <br />fire(;) specified in permit. <br />[.eg~l No3ice <br />This report is required by law (33 U.S.C. 131%; 40 C.F.R. I?5.17). Failure ui report ur ~ailure m report umhl till} can <br />insult in civil penalties not to escetd 510.000 per day of viola•~un: or in criminal penahie, nut to csc:e,l ti'_S.P a , ~ r <br />d.n~ of violation. or by imprisuninem fur nut mm~ than one year, ur by both. <br />FPA Form 3420-I (Rev. 9-881 <br />