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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 houus as an
<br />average per response for some minor facilities, to 110 hours as an average per response for some major
<br />facilities, with a weighted average for major and minor facilities of 18 hours per response, including time for
<br />reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
<br />completing and reviewing the collection of information, including suggestion for reducvlg this burden, to
<br />Chief, Information Policy Branch, PM-223, U.S. Envirouulental Protection Agency, 40l M Street, S.W.
<br />Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office of'Management and
<br />Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregazd instruction directed at entry of that information akeady
<br />preprinted.
<br />2. Enter "Permittee Nome/Moiling Address (and facility namellocation, if different)," " Pzrmi( Numbzr," and "Dischargz
<br />Numhzr" where indicated. (A separate forth is required for each discharge.)
<br />3. Enter dates beginning and editing "Monitoring Period"covered by form where indicated.
<br />4. Enter each "Parameter" as specified is monitoring requirements of permit.
<br />5. Enter 'San, Flo Mzasuremerrt"data for each parameter under "quantity" and Quality"as specified in pertrtit. 'Average" is
<br />normally arithmetic average (geometric average for bacterial parameters) of all sample measwements for each parameter
<br />ob:aiaed during "rLla7iloring Period'; "i+~azinnrm" and ,Lfiuinnun" aze normally extreme high and low measurements
<br />obtained during ";vio;riroring Period". (Note to municipals ss~th secondary trea'~ment requirement: Enter 30-day average
<br />of sample measurements under "Averagz,"aid enter, maximum 7-day average ofsampio mersureroents obtained durng
<br />monitoring period under "rLlaximum. ")
<br />5. Gnt_: 'Ter.~rit Re~rrirmren!"for each parameter under "~r•on/ity"and "Qnaliry" as speci5cd in permiY-
<br />7. Urdr "T.'o F%' enter n;unber of sample measuremc.ri u..rng monitoring pored titLL e:;ceed mv:imum (and;or mini-:,~m
<br />or 7-day 2verage as appropriate) permit requirement for each paranck:r. if none, ester "0".
<br />8. Enter "Fr~;ua, y ,f Analysis" both as "Sample ;.lz ~suuc..a!" (actual frequency cf s:uaplia~ &nd analysis used during
<br />.-onitoring perod) and as "Fzn~ri! R_quira,nsnt" specified in 2 _rmit. (ag. Lnter "Uwrr,"for continuous mcnitaring, "1 /7"
<br />far oce clay per week, "1/30" for cne ciay pee monur, "1/90" for ont day p.r quaacr, etc.)
<br />9. l:nte' "SamFL- 7jF, "both as "S_~.nFle i~1t-srr'~n, _ni"(actual sarpte type usvl derc~ monitoring pcricd) and as ""ensi!
<br />R ~~uirzmart," (e.g. ~nler "uraF" for individual saripL:, "2;!11C" for 24-hou* composite, "1VA" for continuous
<br />monitoring, etc.)
<br />10. R" rero v:e?ations of permit requirements arc reporied, atL:ch a brief exnlanat;on ro describe cause and corn:ciive ac[ious
<br />to be taken, and reference each violation by date.
<br />1 ]. ?: "co discharge" occurs during monitoring period, enter'?'o G~se'~a-ge" across term in place of data entry.
<br />12, Ente,- "1/arrz/Ti,la of Principal Prxutive G~cer" with 'SiguLrr_ cj Pr~r.i/_1 ''r~,.z•!i>,e Gfft, er of Aulhoriz~d
<br />Agznl, ""Telephone Numher,"and Lata" at bottom of form.
<br />13.:via:? sig.:ed Report to Office(s) by date(s) spxified in pe.-n,iL. Pctaur cop; for yom~ re.o;ds.
<br />.:. !:o-a dc:ai'ed instructions for use of this Dischun~ i~P,nilo, ing .~p.rt (Dbr'12) form nay be obtained from Cl~ice(s)
<br />specified in permit.
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<br />This cepor'i is required by law (33 U.S.C. 1318; 4-0 C.F.R. 125.2'7). Failwe fo report or failure to report truthfully can result in
<br />civil penalties no[ to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation,
<br />or by imprisonment for not more than one yeaz, or both.
<br />SPA Form 3320-1 (Rev. 03/99)
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