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<br />Paperwork Reduction Act Notice
<br />Public reporting burden for this collection of informatioD is estimated to vary from a range of IO bents as eo
<br />i average per response for some minor facilities, to 110 hours as m average per response for some major facilities,
<br />w+lh a weighted average for major and n»nor facilities of ]5 hours per response, including time for reviewing
<br />instructions, searching existing data sou~ces, gathering and maintaining [he data Deeded, and completing end
<br />reviewing [he collectioD of informatioD. Send comments regarding the bur"!en estimate or any other ~cpect of
<br />this collection of info~natioD, iacludin~ suggestions For reducing this burdeD, to Chief, Information Policy
<br />Branch, PM-223, U.S. Environmental Pnxection ,4geocy, 401 M Stnzt, SW WashingtoD, DC 20460; and to the
<br />Office of Information and Regulatory Aff.+irs, Oftic_ of Management and Budget, Washington, DC 20503.
<br />General Ins..*.ructions
<br />I. if form h:u been partially wr~plcte:! by propriating, disregard instructions directrd at eotry of that information
<br />already preprwted.
<br />2. Enter 'Pernrirfc•~~ :t'arne~tlail•ng AdJre.cs (and Caciht" rameJloq[ioq if diBerenQ," "Permit Number," and
<br />"Discharge h'un:ber" nhere in:':~caWd. to sepal :,e form is required for each discharge.)
<br />3. Enter dales begmniug and endi :g '..lmriro,~:n~ i'~-iod" ~~•rrrcd by form where indicated.
<br />4. Enter each "Parnmetrr" as spc> rfied ii: monuonug requuemcnts of permit.
<br />5. Enter "San:pie L1ra,~rernQnr' ~.t:i~, for c;,ch p,un,D::er , ^:,':.r "Qi:anriN" m ~ "QualrN" in units specified in permit.
<br />".ivernge" is nortnaR, arith:ndir ~ . ' (;e:,rua:.c ::,n,ge for bacterial uammetcs; of all sample measurements
<br />for c:xh nararnetcr 7hralne:; :: ' ~LL.'r, .: ,nn~ ",. /.,d' "~laxrnuun" and "Afinimnn:" are normally extreme high
<br />and low r.+.ea~,ucm-r,t" nittaii.cd m:r.~~ ' lloni:or r~ ~,'.;,:1." (Note 7~ municipaa ""ilh secondary uwtmenl
<br />requirement c,.'r '.a-da" at:r.:yr ;,~ .t:nc'e ir.ea:,a•a ,: eta ~mder "A"z,,:gr," and cnier maximum 7~ay average
<br />uf'sample mr2:are men', obtair•j dun ;, monituiinf pe' .~d ~ctder '.d larimvm
<br />6. Enter "Pennif .Rrga,rrmr•nf" .o' er,.-,; o'.r ,;r:ter i r.: ~~ ,_ :.nary" and "(.'u~'i..i' as specified in permit
<br />7. Under ""'e ~~" :n[er Dumb^~ .. .,~,~; I: ~neaei t:~,r,a~ ~.'c~^g monitor:n,, period that exceed maximum (and/or
<br />minimum. or 7-! ;y s"er;g+; a cppr:pn :':) p:rn:i• rcq~~i-rmsnr for each parameter. If none, enter "0".
<br />R. Enter "Frzyurr. ~~ .. ;cl:.r:~ a~:h s ' °unr1, /lir.~~ :r;rn~nr" (:,arul frcquenc~ „f sampling and anal}'sis used
<br />during monilc-'.1, (-ri0(i; ;u,_ ., P~ •n,;r RPyI:'rQ/qi /•^ specific-d in perndt. (c g . Enter "Corr," for continuous
<br />monitorin„ "r " fn; nnf da}' "_. "'.:; i ,C' `c..~ae r r ~ per month, "/'9a" for one day per quarter, etc.)
<br />9. F_nter "Samp,'e l oe" bosh a: '.;:,. r/ :inn>~>renr" L,.,,tal ssmp:c t~pz used during monitoring period) and as
<br />"Permit Reysrvrnenr," (eg\ -iw•r ''i-^~" far utdivtdual santp~e, "?vi'!"' (or 24-hour rnmposite, "N'A" for
<br />continuoac momtennv, etc.)
<br />]0. Where violaticrs of permit ree:~remc.tt:. ore r',: ~nrcd, [.u•~ch a brie.` e~pi..nation to describe cause and corrective
<br />actions taken, and reference eac:. "ioln:inn Sy dais
<br />11. I("no discharge" oC=iris during mr, tito uig peon! e:'ter ",Vo Discharge" across form in place of data entry.
<br />12. Enter "TJeme?ille oI Prrncipa Esecu'it e OfJi.-c:" with "Signature nj Pn acipal £xeculive Officer ojAurhorized
<br />Agerf," "Telephone .Number," and "Dare' at bottom of farm.
<br />i3. Mail signed Repot, to Ot!"ice(a; ~~ ua"e~ s) specified in pernitt. Retain rnpy for your records.
<br />14. More detaaed instrucuon, fog u~c of This T7schn~r~ Afor, rering kepcrr (Dd rR) form may be obtained from Office(s)
<br />specified in permit.
<br />Le~ai N~ttice
<br />This report is squired by taw (33 U.3.C. i3'P.; :U C.A.R. 17.5.771. Failure to , •port or failure to report truthfully can
<br />result m civil penalties not to exceed S ! U,OW per day of violation; nr in crimiuai penalties no[ to exceed 525,tJ00 per day
<br />of violation, or by imonsonment far not mots than one year, or by both.
<br />EPA Fornt 3J:0-1 (Rev. OS-951
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