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~ Paperwork Reduction Act Notice ~
<br />Puhlic repor'.iog burden for [his collection of information is estimated to vary from a range of 10 hours as an
<br />a~'era Yr nc` r'.Sl~...nr. :`n: >: ,: tic uirti: ~: fn..~: :G i 1^ h~.%UrS ;.; a:: ..,~ ~ r TC' ~° fD' DTP ~ T fill - ~
<br />with a weieh[e;l nveruge for major and minor fecihhes of t8 hourx per response, inctuomg [role for rcviewmg i
<br />instrvctions, searching ex~stirg datz sources, gal'nenng tend mainrainind thn data ^rxwlai. a,id completing and I
<br />I reviewine lbe collection of ulfurma[iou. Send cotnmcnls regarding the burdco estimate or any other asput of 'I
<br />this collection of information, including suggestions for roducing this burden, [o Chief, Information Policy ~
<br />Br~..nch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washington, DC 20460: end to the i
<br />'I Oftce of Information and Regulatory Affairs, Office of Management and Budget, Washingtoe, UC 20503.
<br />I. - -- - -- --- - - --- - - - - --------- - - - - -~
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />already preprinted.
<br />2. Enter 'Permi((ee h'umeihfnrlrng Address (and facility nameJloealion, if differcul)," "Permit Nuurber," a,id
<br />"Discharge Number" where indicated. (A separate form is required for each discharge.)
<br />3. Gni~r d.itCS bcgtiuun(; imd cndinF ".fnnRnrnrg Percd" covered by form µ•here indicated.
<br />4. Enlcr each "Parnmrlrr" ;is. spccitlcd in monitoring requirements o(pcrntit.
<br />` ~utci "::,r,q,;~ .'~.,:,r.,::;•r,r.°nr .,~ .t, i!n ~=~ ,,,,,::,,- "! umrh~ m umis sncc;ficd in pcrntit
<br />"4rr•rggc" is nnrnlali\ an:hmctic average ((~,comctnc average for banenai paiametersi of all sample mcasuremnus
<br />for c.?ch parameter obtained during "Sfomn,rur4 ,,^:rind', ".1fariun,m" and "!.Irnunw:." are normally extreme high
<br />and lol\ mc.2suremzius o~tainca dunng ' l h,nirnrua; !'error!" (Noic l.. rruuicipn,. \\ith secondary treatment
<br />reywrentent. Enter 30-d:r; average of sample incaswc.ucnts under ",h~ero~:•," .,rid enter maximum 7~ay aeeragc
<br />of s„mp!c m.,_,..rcm^^'s cblair.cd,(.Jr.n~• ,•,cnii.o~n~• „ ,~n~l under "Alnrunum 'y
<br />6. Emir "Penn! Regrurr•mrnr" for each pararndcr undo ~ "UreantitY" and "U~rnlilT° as 5pccificd in permit.
<br />;. undo ":\'o Ems" enter nwrSr Gf sample :.._ ~_:-c_.^.!c d::.^:rig mon!!ono;; period that a>~rxti maximum (ann/nr
<br />' minimum or 7-day avemec as appropriate) pe^nii rcnerement for each parnme[er. !(none, enter "0".
<br />$. Fnirr "Frai,u:•nr,i ,,/ .!Holt-cir" both ats ".1~~nrole 11r~~„extent" (actual frequency of sampling and ar.'_ •aia used
<br />du..^.p r.: ag p'_u _j .._ ~ ,., „ ...,,.. ~,.:_' .' !cg Enlcr „r •..,r~ .,,...nmmnous
<br />uiunitoi iug,~"/~7" for one day pu s~cc6, "I'30" for occ da, per mantic "/"r0"•(or ape day per euarter. eic )
<br />Y Cmcr ~'.S'urgPL~ y,,•i,,... iw;l: .... ":iu~^.l ~i ~ .r. --~,..i..-.r,• .r^. .V, ~., n:, n,nn!(nnng f~r'r:;l -i. .
<br />- .. ~'-.uiC, ": ::..~. ~. ..;. ...::.. ~~..: .....,.,r.. ~~_ rn. ~. G.. 'J.1_hn,v COm c!(D '.\,..; rn.
<br />r'rrmrr hr,fuvemrm, tl.g.. __ pc
<br />continuous montoring, clc )
<br />10. Where violations of pemlil requirements arc reposed, attach a brief explanation [o describe cause and cortedicc
<br />actions taken, and reference cacti violation by dale.
<br />11. !f "no discharge" occurs during monitoring period, enter "1'i. Dr.mhnrge" across (pent in place of data entry.
<br />12. Enter "Name.•Ti!!e ojPrincrpa! Executive p~cer" with ".Signature oJPrincipn! Executrve Officer nJAuthorized
<br />Agent," "Telephone ,Number," and "Dale" 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 this Discharge Afnni(orrng Report (DMR) 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 trvthfully can
<br />result in civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />EPA Forvt 3320-1 (Rev. 08-95)
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