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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 />ayerage per gesponse for some minor facilities, to 110 hours as an average per response for some major facilities,
<br />Witb'a weig4ted average for major and minor facilities of I8 hours per response, including time for reviewing
<br />irisWCtioas,~searching existing data sources, gathering and maintaining the data needed, and completing and
<br />reviewing tbr: collection of information. Send comments regarding the burden estimate or any other aspect of
<br />this collection of information, including suggestions for reducing this burden, to Chief, Infonmatioo Policy
<br />Broach, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Offce of Information and Regulatory Affairs, Office of Pdanagement and Budget, Washington, DC 20503. •
<br />General Instructions
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<br />1. If form has been partially completed h; preprinting, disregard instructions directed et entry: of that information
<br />already preprinted. _ _ ~.. ~..
<br />2E Fater "Permit(ee Nomes~failing Address (aad fadlity namdlocauon, if different)," "Perini! Number," and
<br />"D!.scharge A'u,nber" where indicated. (A.separale form is regnirad for each dixharge.)
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<br />~: Ehtet dates beginning and ending ';4lnmrurmg Period" covered by form where indicated.
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<br />3 4: Ehier each "Parameter" a; specified in mottitorittg regttirements of permit.
<br />~5: Enter "S'ample dfrasurement" data fur ~.xh paameter undo: "Quantity" and "Qual+ty" in units specified in permit.
<br />`' "Acerng~" is uormatlr arithmetic overage (geo!netric average for bacterial paramelersl of all sample measurements
<br />- for each parameter obtained during ",1 ;'-,.aitorinc Period'; ".lfaxirrmm" and ".Afinimurn" are normally extreme high
<br />~~ ~ and law mea_rucments obtained dur.ng ".11n,~uonng Period." (Note to municipals with secondary treatment
<br />requirement: Enter 30-daj avcrape of sample meac;rremcnLs wider "Average," and emer maximum 7~ay average
<br />of sample measurements obtained during monitoring period under "6farimum.')
<br />6: Enter "Permit Requirement" fur each poi: !;peter under "Quantity" and "Oua(ity" as specified in permit.
<br />7,~LJoder ",Vo Fes" enter numbar of sample u.easunnents during monitoring period that exceed maximum (and/or
<br />' minimum or 7~ay arrragc as appropriate) permit requirement for each parameter. If none, enter "0".
<br />~:');nter "Frequency rjAnolvsis" bc:h as "Sun;ole A;~ueurn!ent" (achra] frequency of sampling and analysis used
<br />during munitoring period) and as "r^ern•rt Requirec!enl" specified in permit. (e.g., Enter "Cons," for continuous
<br />'. ' ,monitoring, ° li7" for one day per we`k, "L't0" for one'day per month, "1/90" for one day per quarter, etc.)
<br />;9. Enter "Sample Tj~.e" both as "So.-:pL ,lfenruremen:' (actual sample type used during monitoring period) and as
<br />"Permit Requirement," (e g., Enter "l_==°oi," for ind~l+tdhal samplr.. 24HC' for 24-hour composite, "N/A" for
<br />"," 'continuous monitoring, dc.)j
<br />LO. :Where violations of permit requirements sr~ rcpor!ed~afhch a brief explanation to describe cause and corrective
<br />actions taken, and referen.-e each •: iolation bs date.
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<br />fi. Yf "no discharge" occurs dunog monitoring pPri.~, cuter ",ti'o D!scha: he" across form in place of data entry.
<br />'Enter "Name~!?de ojPrincipe! F_'xecutiv~ Q~cer" •,vi~h "Signa(ure : j Principal Execu(ive Officer ojAuthorized
<br />;4gert(," '7elephone Nmnber,"and `;7a[ °' a+ boK~m of form.
<br />Mail signed Report ro O!Ticels) by date(s) spg:if:A ~n permit. Retain copy for your records.
<br />More detailed instructions for use :,`:his D;~charke ;.loniroring Repo,•i (DMR) form may be obtained from O6ce(s)
<br />specified in permit.
<br />~~,: = Leal Notice
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<br />' report is required by law (33 U.S.r' 1; i%; ~:~ t=.F.R. 125.27). Failure to report or failure to report truthfully can
<br />It ~n civil penalties ant to exceed S] O,C.00 p:;r dar ct' viulat!rn or in cnrrtina: penalties not to exceed 525.000 per day
<br />o `1W'o~atioo, or by imprisonment for not moro tb?n .mr rear, or by bath.
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<br />E Ftrtvt 3320-1 (Rev. OH-95)
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