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Paperwork Reduction Act Notice
<br />' P.:hhc ppcrti rg burd•rn for [hie ccl!ccticr. rf ir.fcr-utinn i, jai mated t; ~.ar~ `:; -.~ . ;..,,..: , , 1G it~~nlr. as an
<br />average per response for some minor tacihtles, to 110 hours as an average per response for some major facilities,
<br />with n weightu; nvaxgc fm majw wid uunul facilities of ]o buns per response, mcluding [lure fOi revtewmg
<br />ins[ructioos, searching existing data sources, gathering and maintaining [be data nee:dc;rl, and wmpletme and
<br />', reviewing the collection of information. Send commrnts regarding the burden estimate or any other aspect of
<br />i, this collection of information, mduding sueges[ions for reducing this burden, to Chief; lnfnrTrlatinn Pnliry
<br />Stanch, YM-223, U.S. tnvironmental F'mtrx~uon Agency, 4D1 M Slrrrl, SW Washington, DC "?0460; and to the
<br />it Office of Information and Ragula[nry Affairs, Office of Management and Budget, Washington, llC 20503.
<br />General Instructions
<br />1. if form has been partially completed by preprinting, disrogerd instructions directed at entry of that information
<br />already preprinted.
<br />2. Enter "Permi!!ee Name/Mailing Address (and facility ttamellocation, if different)," "Permit Nu/rrber," and
<br />"U+.cchorRe M1'umher" where indicated (A separate (omt is required for each discharge.)
<br />3. Fnler dales beg!nn!ng and endutg "llnnit-nnl; Pennd"covered by form where indicated.
<br />4. Enter each ' /'mnnnvr: 1s specdled tit ntonuonug regwrentents of permit.
<br />5. Enter '~1'mnple .1 fea^o~rmenr" daL: fnr each parameter under "~hlmurt}" and "!)ualrtt" in traits specified in permit.
<br />":I verng e" is nonn:dly ariduncuc ac eragc (gcomclnc average for baclcn;d parameters) of all sample measurements
<br />for each parantctcr ob~:incd dun,,^.o ".llunrlr;ring 1'cnncP'; "t/ori/nom" and "11)nimum" arc normally caVemc high
<br />and low measurements obtained dunng ",tlorurururg Peru/d." (Note to municipals ttilh secondary treatment
<br />rcgmr mcr.l E.^.;,. ~"-;!- of :, r,i;!^ .,"~,;rcr.: rd° h.. aha ..:d enter ,,,,, ~in,um 7[laq crags
<br />of sample measurements obtained during moniionng penod,undcr ".Varinuun 'J
<br />6. hater "Pernut Heywrrmenf' for each Darantctcr under "~Juannly" and "Uuuluv" :rs specified in ocrmil.
<br />"! finder "A'o F_X' curer number of c~mnlr. mcncurnlcnts donne mnmtnnne nennd that rxceerf maximum (and)n-
<br />mir.;mcm or 7-dap . c-ae.: ,.~ appr,:pr:.. ~.:) r,:::,.., .a;;:ircn:z ;: fcr _oc` p;;;..;tc:cr ]f ;io„c, cc,cr ,. .
<br />..
<br />~. G!:!C! r. ~(..I!'P^(; If ::': L'I: t:] ... .. ,. ~.`. .1 L:Ot1/ .`.r,:L`:: •.••~.:N .. ... .~ ••c•'L'C;:V J1 .~.•~~n~~ ~~ 1JU a::Ii.':` .-......
<br />' Y ! .......i.....o ..:5 u.rn
<br />during monitoring period) a;td as "Prnur! Rrquireuu•rd' spe+:ificd`in penult. (c.g , Enter "Cunt," fur continuous
<br />monitonne ° f ~i" f~-.r me ti.:+~ per u~crk "! PR" far nn~ dom. air month "r V(' jar nn.~ ~~i: nSr n~l~n;-r, ; !r )
<br />Y. L.IhCI .'1W/If4a % Pf•~ VUiI, .,! .rum/plc ,•LOeiu ['r/u'lu tail Ual SIIU~,u +', Nl uolll WiliuK, IuVI,iiUlitlE', illiivul •:hu ,..
<br />"Permit Regwrcmrn(," (e. g.. Enter "(Irish" for individual sample. "?JHC"' for 24-hour composite, "~':~1" for
<br />conlmuous monitoring, eP=.)
<br />10. Where violations of permit regwrements are reposed, attach a brief e.xplanauon to describe cause and coinciive
<br />actions taken, and reference each violation b}' date.
<br />1 L U "no discharge" occurs during monitoring period, enter ".`'u Discharge" across form iu place of data entry.
<br />12. Enter "Name/1'i!!e of Principal Executive Officer" with "Signature of Principal Executive O~cer ajAulhorized
<br />,4genl," "Telepl(one Number," and "Date" at bottom of form.
<br />13. Mail signed Report to Office(s) by date(s) specified in permit. Retain copy for your records.
<br />14. More detailed instructions for use of ibis Discharge.4foniloring Report (DtifRJ fornt 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 S 10,000 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 Fotm 3320-1 (Rev. 08-95)
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