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<br />Paperwork Reduction Act Notice
<br />Public reporting burden for this collection of information is estimated to vary from a range of 10 hours as an
<br />average per response for some minor facilities, to 110 hours as an average per response for some major
<br />facilities, with a weighted average for major and minor facilities of 18 hours per response, including time for
<br />reviewing instructions, seazching existing data sources, gathering and maintaining the data needed, and
<br />completing and reviewing the collection of information, including suggestion for reducing this burden, to
<br />Chief, Information Policy Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, S.W.
<br />Washington, DC 20460; and to the Of£ce of Information and Regulatory Affairs, Office of Management and
<br />Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregazd instruction duetted at entry of that information already
<br />Preprinted.
<br />2. Enter "Permittee Name/Mailing Address (and facility name/location, if different)," "Permit Numher," and "Discharge
<br />NumFzr" where indicated. (A sepazate form is required for each dischazge.)
<br />3. Enter dates beginning and editing "Monitoring Period" covered by form where indicated.
<br />4. Enter each 'Parameter" as specified in monitoring requirements of permit.
<br />5. Enter "Sarrpk tYleasurenren!"data for each parameter under "Quantity" and Quality" as specified in permit. 'Average" is
<br />normally arithmetic average (geometric average for bacterial parameters) of all sample measurements for each parameter
<br />obained during "i~,,~niluring ,^-srioJ'; ",'~/lcinuun" and Minimum" are normally extreme high and low measwcmen+s
<br />obG.ined during '7~;c-;:it•,rine P_ri•.1" (~1otc to m.micipals with secondary treatment requirement: '-:ntcr 3C-day average
<br />of sample measurmcits uode: "Rr~•rags,"&La eats maximum 7-day average of sample ~reasurcments obtained duri~;g
<br />monitoring period under "iv/aximum.")
<br />6. Ente "Penni( Re; nir.,ne:a" for each parameter urdcr "Quantit~~"and "Quality" as specified in permit.
<br />7. Und_' "N, F:" e~dcr nurr$=r of san1:z ,rtas,u~mc :i during .Monitoring period the! c aceed maeimum (avc/or minCt-rn
<br />or 7-dzy avcrsge as appropriatr.) permit requirement for each parameter. If none, enter "0".
<br />8. Enter "Frei,u,+ ~, pf~;;ral)~si,"b~!i :. ~_~,.,^!e iv%_ ~sr.r~meri" (actual frequency cf sampling :.nd analysis used dnriug
<br />:~ionito,-ing p~riud) and as "Fe;~,rii ~~1,~%,-tn:nr"specified in pe-ci!. (e.g. Enter "Conn,"for continuous moniterir„ "1/7"
<br />for one day per week, "//30" for cat day yar mono, "1/90" for one day per quarter, etc.)
<br />9. En[cr "Sa,;:~l. T ~~ . " bctb rs "S_~.rFlr %-'_ _su: _„~ ~nr" (ac~ual s•~mple type used during monitoring period) and as "Permit
<br />Reguireme~rt," (c.g. Eutcr "vr!h" for irdividutl sar„plc, "24H_^" for 24-hour composite, 'i!r/A" `or continuous
<br />monitoring, etc.)
<br />10. 1~~tr c v:claticris of permit rcqui cmcr s c ,, -ctortcd, [iiach a brief explanation to describe cause aid corrective act+ons
<br />to be taken, and reference each violation by date.
<br />11. ?f "no discharge" area -s dw-ing ¢cniUru•:g period, enter "No Cischarge" across form in place of data catty.
<br />12. Enter "Nor;r_/Title of P,-in_iFa! £CJJer/ivz G~__r" willr "Sibnatrn•r ~,f Prin_iF.~l Executive Offi:ar of dalha~iuJ
<br />Agent, ""Telzphom: It4u;r1 ~;, "and "Gate" at bottom of form.
<br />13. ;via.'. sued Tepm, to Cl;tcc(s) by dllr(s) sf~.:cif ied ire purmi[. Retain copy for your records.
<br />I•:. \-.or dciuiLd instructions :o,- us: of this Uisclr,arbs l.J~nitsring 2r,rt (D,Y112J form may be obtained from CTicu(s)
<br />specified in permit.
<br />This report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.2'1). Failure to report or failure to report truthfully can result in
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation,
<br />or by imprisonment for not more Dram ome year, or both.
<br />EPA Form 3320-1 (Rev. 03/99)
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