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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 bouts as en
<br />average per response for some minor facilities, to 110 hours as an average per response for some major facilities,
<br />with a weighted average for major and minor facilities of IB hours per response, including time for reviewing
<br />' iaslructiens, searching existing data sources, gathering and maintaining the data needed, azrd completing ar,d
<br />~ reviewing [be collection of information. Send comments regarding the burden estimate or any other aspect of
<br />this collection of information, including suggestions for reducing [his burden, [o Chief, lnformatioa Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of Management and Budge[, Washington, DC 20503.
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<br />General Instructions
<br />1. If forme has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />already preprinted.
<br />2. Enter "Permittee r~'ame!tfniling Address (and facility name/location, if dillerenl)," "Permit Number," and
<br />"Dischrrge Number" where indipted. (A sepa_•ate form is required for each discharge.)
<br />3. Enter dates beginning and ending ';Monitoring Period" covered by Corm where indicated.
<br />4. Enter each "Parameter" as spaificd in monitoring requirements of permit
<br />5. Enter "Sample Measurement" data for each parameter under "Qunnt:ly" and "Quali0%' in units specified in permit.
<br />",overagge" is normally anthmctic average (gco aortic average for bacterial parameters) of all sample measuuements
<br />for cactl~ parameter obtained during ",1lnnitonex Pern,d'; ".l/arrmurn" and "Afinumm~" are normally extreme high
<br />and tow mcasurenterls obtained during ",monitoring Penud" (?tote to municipals K~Ih secondary tre~iment
<br />regwremenL Enter 3U-day arcmgc of sample measurements under "Average," and enter maximum 7~ay a~.emgc
<br />of sample measurements obtained during monitoring period under ".tfaxirnunr.'J
<br />6. Enter "~ervmt Regmrement" for each parameter under "Qunnrity" and "QuoliN" as specified in permit.
<br />7. Under "No Er" enter number of sample measurments during monitoring period that exceed maximum (and/or
<br />minimum or 7-dap average as appropriate) pen.til requirement for each paramcGr. If none, enter "0".
<br />8. Enter "Frequenty oj.4nalvsis" both as "Snml,le .tfea.curment" (actual frequcnry of sampling and analysis used
<br />during monitoring period) and as "Fermi' RenviremenP' specified in permit (e g., Enter "Cont." for continuous
<br />monitoring, "I'7" for one day per week, "1'30" for one day per month, "1/90" for cne day per quarter, etc.)
<br />9. Enter "Sample Type" both as "Sample .l9easvrcrnent" (actual sample type. used during monitoring period) and as
<br />"Permit Requireu7ent," (e.g., Enter "Grob" fur individual sample, "2411("' far 23-hour composite, "i//A" for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements are reported, attach a brieCexplanation to describe cause and corrective
<br />actions taken, and reference each violation by date.
<br />11. If "no discharge" occurs during monitoring period, enter "No Discharge" across (otm in place of data entry.
<br />12. Enter "Namell'itle oJPrirtcipal Executive OjTcer' with "Signature oJPrincipn! Executive OJTcer ojAuthorized
<br />Agent," "Telephone Number," and "Dale" al bol torn of form.
<br />l3. Mail signed Repott to Vice(s) by date(s) specified in permit Retain copy for your records.
<br />14. More dktailed instructions for use of this Discharge Monitoring Report (D.t1R) form may be obtained from Office(s)
<br />sptx~ in permit.
<br />Legal Notice
<br />This report is ,required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report oc failure to report truthfully can
<br />result in civil~alties not to exceed 510,000 per day of violation; or in criminal penalties not to exceed 525,000 per day
<br />of violation, by imprisortrnent for not more than one year, or by both.
<br />EPA Form 33120-1 (Rev. 08-95)
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