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Paperwork Reduction Act Notice
<br />!Public reporting burden for this collection of information is estimated to vary from a range of ] 0 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, searching 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 Off ice 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, disregard instruction directed at entry of that information already
<br />Preprinted.
<br />2. Enter "Permittez Name/Moiling Address (and facility name/loca[ion, if different)," "Permit Number;" and "Discharge
<br />Numter' where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and editing "Monitoring Period" covered by Corm where indicated.
<br />4. Enter etch "Parameter" as specified in monitoring requirements ofpermit.
<br />5. Enter "SanrFld N,easurament"data for each parameter under "Quantity" and Qualih~" as specified in pemvl "Average" is
<br />normally zridimeiic average (geometric average fcr bectcrial parameters) of all sample measurements for each parameter
<br />oL•ained during ",l~nriroring Period"; "lilaxirnum" and rtiminu+m" are normally exLeme high and low measurements
<br />ob:z`.ncd during "i~r,ritoring P2rio,1". (1`'ote to municipals with secondary trcztmcnt recuircmcnt: Enter 30-day av~ age
<br />of,<~,nple mcasurmen[s under ilverage,"and enter me:imum 7-day average of sa,-nplc measurements obtained dung
<br />monitoring period under ;vlarimunr. ")
<br />6. En:~_~ 'Ter,,.ir l;~°7nireme:r!" for each parameter uadcr "Quantity"and "Quality" as specified i^ permit.
<br />7. :'~ d_: ",1' .. " entryr cumber of sample n-easaement during monitoring percd t~mt e°re~d matir^rm (end/or mir' ._ m
<br />o: 7-d ,y a• c-age as a; ;.ropriate) permit requirement for each parameter. If cone, c ttcr "0".
<br />f.-~;._, " ,_, :_, ;- f.S:•~lais"bath as "S~urtla ;:Ls+=, _m-;u" (actual frcqueac, :fsamplin^ ~vd aaal;sis +,sed duriag
<br />..o^,itming;x: iod) and cs "F,rnnit Ra.7ui;.,;rurt"specified in pc,.r.:. (c.g. Cntcr "~ ;n:,"fnr continuous monitoring, "1 /7"
<br />for ecc day per wak, "1/30" Cor cne day per monC~, "1/90" for one day per quate:, etc.)
<br />~.°nt. ~ "°a,:.t /e TjF: " L-otii as "S. rarle n,~asura,::_>>t" (actuzl szrp1e type us.' dur'r.~ mo.~itoring period; and as ':"e,zair
<br />Fsyn:r~rne,+i," (c.g. Enter "Gnh" for individual sample, "24NC" for 2~-hazer composite, 'SV/A" %nr continuous
<br />monitoring, etc.)
<br />10. ~',"ic:a vi,:'_riuns ofpenni[ *ryuirements are reported, zt~ach a brief explanation to desc,ibc cause r td coaective actions
<br />to b~ tasen, and reference each violation by date.
<br />11. 'i "r ; discharge" occurs duringmonib:ingperiod, enter"~'o Discharge" across fern `.. place cfdata entry.
<br />l2.:-ntc 'iY.~,:r=/Titls rf FrinaiFal Executive G~~_ar" with "Signahrre of Principal Er°_utive O~~'i~er of Aut;rorizdd
<br />Ab>a,: ', ""T~:~/:hon=_ AirmEzr,"and "Litz" at bottom of form.
<br />' 3 :~..a: sigre~ :,eport to Ouroc(s) by date(s) specified in perotit. Retaic copy for y our records.
<br />"c de'<'~d instrucfions for use of this Dis~harga iAorritcring 2:pa1 (I7ivfJjJ form nay he obtained from C,Ticc(s)
<br />. 3eci 3ed in permit.
<br />~.~~~i~ ~©~Iiy~
<br />"this report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Fai]ure 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 than one year, or both.
<br />EPA Form 3320-1 (Rev. 03N9)
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