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GENERAL INSTRUCTIONS <br />I. If form has Arco panurlll nmpktN by prcprintitrp, divepN imtrutem~directeJ at rntry o! that inlormation alrcaJy preprinted. <br />_. Four "PFRMITTEF. N.1Att./M AILINCr ADDRESS lad facility tume/lootimt. if JiRercntt " -PERMfT NL'i1BER.' and -DISCH.iRGE <br />~L'MRF.R- .here indicated. to aelorate farm is required for each ditcharpt.l <br />J Fmer rLris+ hcpinninp anJ pnJinp 'MONRORING PERIOD" eorertd by form there idiated. <br />i. Four resit -P.i RAMFTFR" r specified in monitarm7 requirtnlenta d permit. <br />!. Emrr "SAMPLE MEASUREMENT' dau for each parameter unJer'QUANTITY and 'QUALITY' in uniu rPnilkd in permit. <br />'iVFRAGF" E norrrully arithmnic arerape tyeorrretrir araaR fa Aaeterial patamerenl d all sample measuremmn for each ryrameta <br />ohaind Jurinp 'MOIVRORING PERIOD" 'MA%IMUY' and 'MINIMUM" are aartulls esttente Aiph and br metarements <br />chained dautp 'MONITORING PERIOD' r VOTE, to maniegak .ith se'erldary treatment requirement. rnler SUday avenlx d sample <br />meawneaeats order '/\VERAGE" ad rnm nuaimua~ 7day asenOe d rampk are•axemcnts oboind durinS mm~ario7 period udn <br />'MAXIMUM'. <br />F. Emer YERYR REQQIREb1EM" fa rash puameter under 'QUANTITY' ltd 'QUALITY" as upee~ed m ptrsttiL <br />7. Under 'NO. F7I' carer attrher d aarple re~ee4als dtxea taoaiterutr< period that etteaed ms®aa lad/a rinierm or 7-0ay <br />aaerape » al9reprotl Pamir retPrireets fa etch parameter. If root eater "'0'. <br />B. Eater 'FREQUENCY ~DF ANALYSLT bah m `SAMPLE MEASUREMENT" raatd (regttsey d aaetplia{ cad aaalysu useJ Jump <br />_I ~ ~ 1I arl a 7ERYfT REQUIRFJIENT' OmBd is permit laR... Era YOOMM' for cpdmuas tttaaiterm7. <br />y px aseb. -1/)0' fee eae day pv mrd '1/70" fa oae day per.gtona. ae.l <br />9. Era 'SAMPLE. ME:' bet6 a'SAMPLE MEASUREMENT' lantd sample 4Fr tsd Junet mautorinF periaJt ad o <br />YERYR RF.QUIRE7dILM.' te.p.. Eats T.R7B' fw etdiridtral faarpk.'!iHC' fa ?a-hour caryrdre. 'N/A' fa aoainuous <br />raailorin~, ete.l <br />~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~Lt1Y alaM dal <br />IU. R'HFRE VIOI 1TON:i (IF PERMIT REQUIREMENTS ARE RFPORTF.D. ATTACH .A 8R1F.F F.XPI.ANATION TO DESCRIBE <br />CAUSE AND CORRECTIVE AC77ON5 TAKEN. RF.FERETICF. EACH VIOIATION Bl' DATE <br />1 I. If 'ro Jeelurye" acura dtlrvrS eneitas~ period. rnter 'NO DLSCHAROF' acmes form is plae d mu eery. <br />1. Eater -N.iMF/TI)'I.F. OF PRINCIPAI. F.XECIJTIVF. OFFICER' ruh "51(iV.iTIiRF. OF PRINCIPAI. F.XFCUTVF OFFICER OR <br />AUTH(1R17F.D AGF.ifT.' ~TEI.1?PHONE NL'bIBER' ad "DATE at Aatom of frxm. <br />I3. Marl aiptk-0 Repon m Officetsl M Jatrt s/ ~tcdreJ a permit. Retain copy fa Sax tnvnh. <br />11. Ware Jetaiknl irtartrnkm fa use d Chia DISCHARCiF hIONRORING REPORT tD\IRI form may he uhairrtJ from CMtulsl <br />specifrJ is permit. <br />LEGAL NOTICE <br />This nyon is required by laic' tit US.C. I)la: itl C.F.R. 1:3.:71. Failure to repun ur lailrrrr tp reppn truthfully nn rewlr in ciril petultin rot <br />10 e[CCLJ Slll.laal per Ja) O'1 \'iOLrign: or in CTImiRal pemll ia~ opt to t]CLCJ S.S.Ita1 per Jn\ pf tlplall0lr, ar h\' Impri3palill'0I for rol mate Ihae <br />one lot. or 1'r Mth. <br />OM0~1{ lalrl Q10a <br />1617H <br />rIN V 1S <br />i~1/l/ <br />eat Mi 1aaM e101 <br />3Y3H 3lJV1S <br />