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Paperwork Reduction Act Notice
<br />Fublic reporting burden for this collection of information is estimated to vary from a range of l0 hours as m
<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 `2cilities o. IS hours per response, igcluding time for reviewing
<br />idstrpcticros, searching existing data sources, gathering and maintaining the date needed, and completing and
<br />rdvi4f[i'ilfg the collection of information. Send corunents regarding the burden estimate or any other aspect of
<br />this coG!xtion of information, including suggestions for reducing this burden, to Chief, Information Policy
<br />Branch, ?M-223, L'. S. Fnvironnrental Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of [nfor'nation an.; ReErttlatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />i. 1( form his been partially comriaed !•; preprintv+g, disregard instructions directed at entry of drat informmtion
<br />: beady. proprin[ed. ..
<br />2. Enter •.'Penritrce ~Nmneal;nil%n~ Address (and fau;ih' namc/localion, if different)," "Permit Number," and
<br />"Disc.hcrc•• '1'amber" ~;tern indir-atcd (.A separate form is required for each discharbeJ _~ _,,
<br />3. Enter dates beginning and endin3 ':b/onrturirg t'enou ' coy ^red by form where indicated.
<br />4. Enter cadt "nurwnr r. r" as specfed in monitoring rur_ iremcnts of permit.
<br />5. Emxr~'6ample hfra•t., emrnt" ds... for each .rara~-!cia rr~4.• "Qunntity" and "Qunlirr' in units specified in permit.
<br />':4+~r•ragP" !s normall•; 3rii~r.~^li. ~~•eragc iy:orr•+rc a:c~ +;e fcr bacterial parameters) of all sample measurements
<br />for each param:.'~• ci;lain••u dcrrg "4..`on.r.rinp ' - .:d' ",';nximum" and "Minimurr" are nortnaily extreme high
<br />' ~ar~„~ ;' rind." (Note to municipals eith secondary treatment
<br />and rov nra:~;rrau.s ootained duns:: fon~
<br />reyuirc!nenl. i. n.• ~:)~i;~• avcra~c o"::..r;:~?e ne:r ~•r•~~•,cnts under "Average," and enter maximum 7-day average
<br />of sa,nple ~ne~surcment; ehfau e1 d:!rin-mcn~tonn); pcr:.td under "M::xrmum. "1
<br />6. Emcr "Permit R: y>i:~,r;.,er:"' ic. aaca par:~mer ~ ~ ier "'•r,,.,(ity" and "puality" as specified in permit.
<br />Under "`n G" ::,:.r numbe .tf samp:c m,.~r-.!_n~, erring monitoring periw that exceed maximum (and/or
<br />minimun. ~~ '%-r at aragc n.~j:~ror iar) cetmn rc ;uirrmcnt for each parameter. If none, enter "0".
<br />8. Er.tc• "~-cy>:.: • .' 1:: ,1; : S.~'h ~< " •:rmn,; ah•c ~~.; r. nr" (acn!al frequency of sampling and analysis used
<br />during mnniron ~ f : w'• -ar as "^r •.~~' :4equirenren%" - ^cificd in permit. (e.g., Enter "Conk" for continuous
<br />~nonE[onr; 'r ~' ~ : rac r4..• , . ek, "~ ~~" Cor ere r/~~: cer month, "1.90" for cite day per quarter, etc.)
<br />S' E.de: "S, rr•'. ,ypz' opal! as So•,+ple tdea~.:c:u ~:~" 'acbrat sample type used during monitoring period) and as
<br />'"Pcrr!it 2rr,:•rr.r-.•n~," (e.g, i:nxr "r;rar" for indivmn~!1 s:,mple, "?4HC' for 24-hour composite, "N/A" for
<br />cnntir:uous nwnitonng, etc.l
<br />10. Where >, ~cluuor~ of xnni: reyuirahrents arc rc~mtrd, attach a brief explanation to describe cause and corrective
<br />actions is?:ut, and reference carh v[ohtion by date
<br />11. If "ao discharge" occurs during ,.r~nitorng period enter "A'o Discharge" across form in place o(daW entry.
<br />12. Enter "A'ame/!•itle ojPrrncipal ~xecu[ive Ujfic.•r" with "S.gnature ojPrincipal Executive Officer ojAuthorized
<br />Agent," "Telephone >V amber," and "Dare' at hottum of form.
<br />13. Mail signed Repot to i)t;rce(s) by date(s) speci(.cd in pcnnit Retain copy for your records.
<br />14. PAore detailed instinction~ for use of thrs Disc;arge Afonirur,ng Report (D~t~) form may be obtained from Office(s)
<br />specified in permit.
<br />l,~gai Notice
<br />Thrs rerwrt i~ rtqu~r~ by low (33 U.S.C. 1?1C~ 40 C F.3. L.`.27). hailure to report or failure to report truthfully can
<br />result m civil penalties ant [~. extt'e< St0,t1f~J per day rf vi~lat!cu, or in criminal penalties not to exceed 525,000 per day
<br />of violation, or by imp[~sonmcnl for not .ttore'han .me year, or h~ both.
<br />EPA : arm ;i3d0-1 Q2ev. OR-9~
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