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<br />P~p~rworls Reduction Act l~atice
<br />Public reporting burden for this collection of information is estimated from a range of 10 hours as m
<br />average per response for some minor facilities, to 110 hours as en avers tier response for some major facilities,
<br />with a weighted average for major and minor faciiities of lg hoots per response, including time for reviewing
<br />instructions, searching existing data soureesx.~a{ttering and maintaining the dais seeded, and completing and
<br />reviewing the collection of information. $ : ~ ~ ntsTr~N'ding the burden estimate or my ether aspect of
<br />this collection off information, including su fpr, mg this burden, to Chief, informa[iom Policy
<br />Branch, PM-223, U.S. Environmental Protection. ~ T.-i Street, SVJ Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office t7~~[anagemeo. and Budget, Washington, DC 20503.
<br />~,reneral Instructions
<br />1. If form has been partially completed by preprinting, distegacd instructions directed at entry of that information
<br />already preprinted.
<br />2. Enter "Permittee Name/A-failing Address (and facility nameAocation, if different)," "Permi( jyumher," and _ .
<br />"Discharge Number" where.i~(A separate form is required for each discharge J' - "'
<br />3. Enter dales beginning6~g 'Alonitoring Period" covered by form where indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />5. Enter "Sample A-leasw~emen!" data far each parameter under "Quantity" and "Quality" in units specified in pern»l.
<br />"Average" is normally aritl;me[ic average (geometric average for bacterial paraotcters) of all sample measurements
<br />for each .parameter obtained during ".'Noniloring Period"; "Marimwn" a,.d ",'vlim,nunr" are normally extreme high
<br />and low measurements obtained during "Monitoring Period" (D1ote to municipals with secondary treatment
<br />requirement: Enter ,U-d&} accmge of sample measurements under "Average," and enter maximum 7-day average
<br />of sample mertsureme+as of rained during monitoring period under ",Na:imum.
<br />6. Enter "Permi+ Requirement" for each parameter under "Quantity" and "Quality" as specsed in permit.
<br />7. Under "Na Er" enter .^.urber of sample measurments during mo+utor;,+g period that exceed maximum (and/or
<br />minimum or 7-day a~ crnge as appropriate) permit requirement for each parameter. R none, enter "0".
<br />8. Enter "Frequency o,`Analvs+s" bath as "Sample ,1leosurn+enl" (actual frequency of sampling artd analysis used'
<br />during monitoring period) and as "Pernut Requirerneai" specified in permit. (e. g., Enter "Conn" for continuous
<br />monitoring, "//7" tot one d,y per week, "li30" far one day per month, "I/90" for one day per quarter, etc.)
<br />9. Enter "Sample Type" bath as ".Sampie hfeasurenrenl" (actual sample type used during monitoring period) and as
<br />"Permit Xequirerrrent," (e.g, Enter "Grab" for individual santple, "1~1KC" for 24-hour composi(e, "Nri1" for
<br />continuous monitoring, etc.)
<br />10. Where violations of r,:.tmit requirements arc repor[eri, attach a brief explanation to dts_ribz cause and corrective
<br />actions taken and referetrce each violation by date.
<br />l 1. U "no discharge" occurs dating monitoring period, enter "No Discharge" across form in place of data entry.
<br />12. Enter "Name/Title ojPrincipa! Executive Officer" with "S'igna[ure ojPrincipn! Executive OJ~cer ojAuthorized
<br />Agent," "Telephone Number," and "Date" at bottom of form.
<br />13. Mail signed Report to Office(s) by date(s) specified in permit. Retain copy Cor your records.
<br />14. More detailed irrstruclions for use of this Discharge Monitoring Report (D,4SR) form may be obtained from Office(s)
<br />specified in permit.
<br />Legal Notice
<br />Tlris report is r~uired by iaw (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report ur failure [n report truthfully can
<br />r~esuli in civ,l peoairies not to exceed SIO,000 per day of vio:aciom; or in crinunal penalties not to exc~d SZ5,000 pot day
<br />of violation, or by impr.sonmert for rot moro than one year, or by both.
<br />d",
<br />EPA Forvt 3321}-] (Rev. OS-~~
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