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Paperwox•k ][~eduetion Act Notice
<br />P»blic reporting burden for this collcetion of infonnatioa is estimated to vsry from a range of ]0 hours as an
<br />aJer8g2 per response for some minor facilities, to 110 hours as sn average peg response "or seme mdnr facilities,
<br />with a weighted average for major and minor facilities of IS hours per response, iacluding tine `or reviewing
<br />;vtz.ctions, searching eristng data souraus, gathering and maintaining the data n.eced, and. completing and
<br />rviz,ving the col:ection of'nforma[ion. ~en~ conmer.ts regarding the burden esLnx!z or any other rspect of
<br />Pris .ollzc[ioo of information, including sugges[ioas for reducing this burdec, n C.vef, Irfanratioo 'olicy
<br />Branch, Pit-223, U.S. Eavi-ottmental Prc xtion Agency, 401 M Street, SW FJashia~tou, DC 20460; and to the
<br />Office of Infercvrtion and Regulatory A;1~ i s, Office nF Management and Budget, FJi.hirg[on, CC Z~SC3.
<br />G ~~neral Instructions
<br />1. if Form has been partial'y camn]eted '-.y preprinting, disregard instnctiens dirce's:d at ectry o` that information
<br />a rzady preprinted.
<br />Z. Enter 'PerTittee :Vame%Lfailing /,rl~:zss (and facility name location, S differ.zt)," "~'errnit i/r,raber," and
<br />"7ischn~ge Number" •.i•hcre indicated. ' ~, separate form is required for each disd-arg::.)
<br />3. Enter dates beg nniag and ending 'A1n7 Loring Period" rovercc by form vrnere indi _aled.
<br />4. Ericr ercn "Pm•ameter" as specified in :nodtoring requirements of permit.
<br />S. F'r. er ".Sen:ole Llecsvre+.tent" dare nor ^ct parameter under "Quantity" and "Qi•ali~'i' in urns specified in permit.
<br />"Avera,¢e" is ~onnrl!g z iLhme6c avc c e (gcomel~ic a?•cnge:o; badcrial para-*~ e-s) of al' sanrlc mtasuremer s
<br />fa each ~u:am°ter e'~ta~nec' doing ". ~~ni'nrm,q ,°e.-iod"; "ir1¢:im~nr" and ".~finuv~~ ,P a; ~ normal]} c~lremc hi ~`
<br />tnd tor: mess ueme~ts obla~;cd [: a ':r lonimnng Period" (Xo[c lc iru.ci :els ~.iih sn:ondar; irealmw'
<br />tc; uirnnr.~.C F.^'c' 10 .'ay zverage r- ;am plc mesurcmcnts under ".fve,•age," °. c ~n[cr n~s~imum 7-iay avcra~ c
<br />of ;nm _Ir.. m;:asaremc is obtain :d do i ; mo~,titoring f.eriod under "d/aximum ) J
<br />G. Lnlcr "?crmir Kegvirernrnt" for ezc ~ ;: ranteter under "Quentity" and "Quority" ~ s-:cifird in pe rnti!.
<br />7. Under 'iJo Fs" c~te~ rurebe; of sarnp'e mrasurmcnls during monitoring :ar?c;; '.prat c.ct~d ma::imum (and's'
<br />~ninimun nr 7. ~,~.y a,.•cr:ge as apnrcp^n[e) ;c;mi: 'ec;uirement for each prrarrele ~. -non., enter "0"
<br />3. .-tr-r 'f'requency of Anolvsi?' bot` "Snrnple A1r~asunru°nt" (act-,~al'rrq._e.ic; c- camp' ing ant a.utiysis uses:
<br />taring moriloirg p nud) enc. s'`-• uti: HequD•enrent" spxified in pcrnil. fc.g. Entc "C'r•: t" fet ronunuc
<br />rnnitonng, "1'7" fo- ore d~.y e- w°r :. "l.'30' for one day per mom: h, "/•9t7" for ^ u day sr qu.rrter. ele.)
<br />9. Enlcr "SanrP'e Ttgre" :.o[]t 2s "San, p'r '~lrosuremrnt" (actual cam plc :;';e used during mraritor ng period) znd s
<br />~'rernut Rzgmremer t," (e.g., `~'n[er ;,rr 5" for individual san~lc, "~~;IC" fcr ?4-hnu• co a.positc, "A'!~" for
<br />~ontinueus monitoring, etc.)
<br />2 V:hen: ~ iolslinns of perntit requiremc GIs arc reported, attach a brief explanatin :c des-n§e cause and correct ::
<br />alions taken, and reference each violation by date.
<br />11. Lr"no dischaq;e" ctecurs during monitarint; period, cote- ",\'o Discharge" across `oT in p!a~:e of datz entr}•.
<br />12. Enter ".'Jnrne~Title ojl'rincipal Fxen,riv~ Olffcer" ?vilh ".Signature ofPrincim~r ;xecu'i.e Opicer afAuthori-.~d
<br />F,~ent," "Telephone .'?'umher," and "Cole" at bottom of fo rm.
<br />D~(<iit :igncd Report to O1Fice(s) by ri= cs) 7ccified in pern»t. Retain cepy for ynur records.
<br />1Fl. P.(ore i. G^,ilzd instruc(ions for u5^_ of , ~~is l)ischorge Alonitoring Rennet p7bfRj forni may br obit ncd ftom Oftic-(s)
<br />specified in penni!
<br />]Lregal Notice
<br />T~is report is rtquired }.y rev. (33 U.S.C. 1 313; •:0 C.Y.R. 125.27). Failure to report or failurz to report truthfully r in
<br />rt ~u'~t i-, civic ;eau t es rot to exceed S10,a'1!7 pe- 6ay ofvio!a[ion; or in cr:-ninal Pena!;le not ~c ~oxce~d S75 000 ter r ~-•
<br />~,. vicl.,.ion or by imprisonment far no[ mrnz than one year, or by both.
<br />E'F'A, ~ rem :'3201 (Reti. OS-95)
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