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Paperwork Reduction Act Notice
<br />Public reporting burden for this collection of inror-mation is estimated to vary from a range of 10 hours as m
<br />average per response for some minor facilities, to 1 ]0 hours a~ m average per response for some major facilities,
<br />with a weighted average for major and minor fa~~ilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining [he data aeeded, and completing and
<br />reviewing the 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, lnformation Policy
<br />Branch, PM-223, U.S. Eovironnteatal Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of hfanagement and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />already preprinted.
<br />2. Enter 'Permittee .Nome%blmling Address (and facility nameJlocation, if different)," "Permit Number," and
<br />"Discharge ,Number" where indicated. (A separate form is required for each discharge)
<br />3. Enter dales beginning and ending ";Monitoring Period" cocerzd by form where indicated.
<br />4. Enter each "Parmneter" as spceified in monitoring requirements of permit.
<br />5. Enter "Sample .4leosureruent" data for each pa,'amcter under "Quantity" and "Quality" in writs spceificxi m permit.
<br />"Average" is normally anthmetic average (geo.~tetric average for bacterial parameters) of all sample measurements
<br />for each parameter obtained during 'Stloniturir,g Penud", ".llaxunurn" and "Alimnrurn" are normally extreme high
<br />and low measurements obtained during ".1looimring Period." (Note [o municipals with secondary lret~tn~ent
<br />rcquiremenr Enter i0-day aventge of sample measurements under "Average," and unto naeimum 7~ny a•,eragc
<br />of sample measurements obtained during monitoring period under ",t loximum.
<br />6. Enter "Pennrt Requirement" for each parameter under "Quantity" and "Quality" a:, specified in pcrnil.
<br />7. Under ",No Er" enter number of sample measumunts during monitoring peric•d that exceed maximum (and/or
<br />minimum or 7-day average as appropriate) pcrnit requirement for nch pammeter. if none, enter "0".
<br />8. Enter "Frequency ojAnnlvsis" both as ".Sample .4leasurmenr" (actual frequency of sampling and analysis used
<br />during'monitoring period) and as "Fermi! RenviremenP' specified in perm[. (e.g., Enter "Cont." for continuous
<br />monitoring, "/!7" for one day per week, "1'30" for one day per month, "J/9D" for one day per quarter, etc.)
<br />9. Enter "!Sample Type" both as "Sample ,Llensuremenl" (actual sample typ,: used during monitoring period) anc as
<br />"Permiq Requirement," (e.g., Enter "Grab" (or individual sample, "2JHC" far 24-hour composite, "IJ/.q" for
<br />continuous monitoring, etc.)
<br />10. Where Niolauons of permit requirements are reported, attach a brief explanation to describe cause and corecuve
<br />actions oaken, and reference each violation by date.
<br />11. If "no discharge" occurs during monitoring period, enter "No Discharge" across torn in place of data entry.
<br />12. Enter "~ame/1'ille ojPrincipal Executive Officer" with "Signature ojPrincipnl Executive OjTcer ojAulhorized
<br />Agent,"I "Telephone Number," and "Dare" al boi tom of fore.
<br />13. Mail signed Report to Office(s) by date(s) specil fed in perntit. Retain copy for your records.
<br />14. More detailed instructions for use of this Discharge hloniroring Report (D.MR) fore may be obtained from Office(s)
<br />specified in permit.
<br />Legal Notice
<br />'This report is'irequired by law (33 U.S.C. 1318; 40 (:. F. R. 125.27). Failure to report or failure to report truthfully can
<br />result in civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed (25,000 per day
<br />of violation, or by rmpnsontnent for not more than one year, or by both.
<br />EPA Farm 3320-1 (Itev. 08-95)
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