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Paperwork Reduction Act Notice
<br />Public reporting burden for [his collection of information is eslimatfl to vary from a range of 10 hours as an i
<br />averagz nzr redw:nvr For .nmr minor facii:l!tt, In I Iii hour. ~: ~~ ,n ._~~....,,,., ~..: ,i._,._..,:., r ... ....... ..... .r fa: it fir:,
<br />with a weighted average for maim and minor facilities nF 1R hor:rs net respons_, including time fo: revicwmg
<br />instructions, searching existing data sources, gathering and maintaiauig the data needed, and completing and ,
<br />reviewing [he cnllertinn of infnrmahnn Send r•nm_ments feverdiag the burden eetitnat:; or 'any othor aspect of
<br />this collation nF information, including sug~~rstions fur rrducing this hurdzn, to C!;iaf, Info ~„lien Policy
<br />Hr~ch, PM-223, U.S. Emamnmental Prot,:ction Agency, 401 M Slrat, SV! Washington, DC 20~tt0; and rn the
<br />Office of information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. I( form has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />already nrenrinted.
<br />2. Enter 'Permrrtee S'mne tlnlhng .4 ddress (and facility namellocauon, if diiferenp," "Permit Numher," ar,d
<br />"DischnrRe 9'umber" where indicated. (A separate form is required for each discharge.)
<br />3. Enter d:ucs bcgiuuiug ami ending "tiumtr,nrr~ Prrrnd" COVered by form where !r!d!c:+tcd.
<br />J. Enter each "Parame!rr" as specified m mm+iinrinp. requirements of permit.
<br />toter .. .~ ..
<br />_. '1,'ain pii 1: er_Pai'd!i12ii:" daC3 tvr iai.il ii,ti,i f:ie.ibi ^:wc: /l u:. ni,iv a11U "l/nrl4rl m Un115 4~1(tt'I: ~I~•r: ~ pefmll
<br />": h'crngc" is nonnall~ anthmetic average (geomaric a~cl age t'm badcrial pamnlelersj of all sample n.casurements
<br />for each parameter obtained dnnng ":1;unrforur,u Prru,rP'; "11ur,mum" and ",4lrnimunr" arc nonnalh' avtreme high
<br />and lo« measurements obtained durng ".'Jura G>rur.4 !'rrrc,d" (tiote to municipals i+ii6 secmidary treatment
<br />rcgmremcnl~ Enter lU-dav average of sunplc mrasurcmcros under ":L•r'roge." and enter mas+mvm 7-day average
<br />Jf cimplC meaSUi CiiiC iliS Gbll: i:~4 (i,li:nL :h~:iaiJi:i,~ tsruui Uur:Cr' Diu run urn, ")
<br />6. Enter "Perini! Requirement" for each pard:rdcr under "(Juana^r' a.".d "JuahN" as sD^.c:Ce~ in pemlil.
<br />?. Undcl ",Cu Fk" eater number uC .ampic nuasurnunts during monitoring period tiiu; cxcr_d maximum (andlor
<br />minlmnm nr 7-dev 24rraor a5 apprppn~lr) prrm~t rrnrUl rCmrN rnr Pa_h pa.•ameler. 1(nnn~~ ,•~: er "f)".
<br />k FrltPr "6.e./nPn~l~ r.( 1nr.It.r)r" Ln,6 ~o •'l'r, o.~L. 1L,..,,,.-.,.....!n ('.'.°r~~l M1~y ~CU~ Cf °~..,Ylj.. o. ~..A artatySlS li'.C~
<br />dr,r -ly n „n„o-t g pcricG} aaG as -~ u: „~ yu,r~,m„. spsil-:td .f. ytTLi (c g . t:nla ' (v :, ,c• connnwus
<br />momtonng, "I ~7" far one day per week. I.30" for one day per month. ' Uv0' for one day per quarter, etc )
<br />Y. t'.^lef ".~'alll(rti lo-pr" Guth rL`. '. ut,rr/di 'sir r. ub rnir•ri" (.0.llLli i.:n a:i~ i~pi. ub-;J uul:lig ^lOll+irHli:~ rJ:vvi -+~ as
<br />°I'ermu i2egvvernenr," (e.g, liner t,rn7 for indis muai sampie, _dnt ~ for L•+-hour comoosnc -`~+~~ iul
<br />continuolu monitoring, etc.)
<br />10. N'herc violations of permit requirements arc reported, attach a bncf c.~planation to describe cause and corrcdice
<br />actions taken, and reference each violation by dart.
<br />11. If "no discharge" occurs during monitoring period, enter ",~'u Dr~chur7te" across form in place of data entry.
<br />12. Enter ",Ncme,Title of Principal Executive Officer" with "Signature ojPrinetpn! Executive Officer ojAulhorized
<br />Agent," "Telephone Number," and "Dale" at bottom of form.
<br />l3. Mail signed Report to OtTice(s) by date(s) specified in permit. Retain copy for yolu records.
<br />14. More detailed instruMions for use of this Dt.scharge hfnniloring Report (DAfR) form may be obtained from Office(s)
<br />specified 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 or failure to report truthfully can
<br />result in civil penalties not to exceed Sl0,ooo per day of violation; or in criminal penalties not to exceed 525,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />EPA Form 3520-] (Rev. OS-95)
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