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Paperwork Retl~ction 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, 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 Office of Information and Regulatory Affairs, Office of Management and
<br />Budget, Washington, DC 20503.
<br />general Instrr~ctions
<br />]. If form has been partially completed by preprinting, disregard instruction directed at entry of that information already
<br />Preprinted.
<br />2. Enter "Permillee Name/Moiling Address (and facility name location, if different)," "Permit Number," and "Discharge
<br />Nun:bzr" where indicated (A sepazate form is required for each discharge.)
<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 perrni[.
<br />5. Enter "S~npla Mvcuremznt"data for each pazamcter under "Quantity" and Quality" as specified in permit. "AvzrJga" is
<br />no,~nally arithmetic avcmge (geometric average for'oacteriat parameters) of all sample measurements far each pammetcr
<br />obtained during '9L1;rzit-,ring Pzriod'; ",Llr:iz;nu;z" and Minirurm" arc nomally extreme hig;t and lots measurc~ncnts
<br />obtained during ".'.1•.nitr,;~ing Pzz-iod". (~'otc to municipals vrith secondary treatment rzgliremcn[: ~nlc: 3C-day accra;,c
<br />of samplr. nteasurcmcnts under "Av~rag~,"and enter maximum 7-day average of sr rple mzasure-Went;, obained di:r.ng
<br />monitoring period under "tY.aximurn.")
<br />6- Enter "Pzn:,ir R.tyuiran~mt"for each parameter under "~zmntif~"and "Q:raliq~" as specified in permit.
<br />7. Urc c- "/t'-, E." e,te- nvmbe,- of sample m~:.urer,en' dur'ng manitcr•~g .-cr.nd teat c:cecd mr~cr,:.m (. nf.'rs n-inirrnm
<br />or 7-~: y average as e,-.propriato) permit rcquir~mer--: for each pammetc,. Ifnone, cnr.r "0".
<br />S. ;?nter "F,a:ir y ~,f."..,_hsis"both 2s "S~,a; 1. l~:_~surera.•rr" (actual fragcacy ofsc*nplin,~, and atr',sf: uscC deri^±;
<br />monitoring , eriod; an { as "Fes%;dt 2y;rir,:nrJ;1~" specified in pcmtit. (ag. Sntcr "Co. , ' ;c- cantin[ous menitarin„ "t/7"
<br />far ono day p,r vrcc!:, "1/30" for one day per month, "!/90" far one day per quarter, e: ~ )
<br />S. Enter "SamrL• T~;^:"both as "S~-r.~L L1 _~ee,•~;;r, r t" (7cttlat sample t;;ta rscd dt~r,r~ r„nnitoring pcrcd) anc as "^_,-,:;i;
<br />Reyui,rm>;;t," (c.g. Enter "Cr.ah" for individu°I rumple, "14HC" far 2~i-hers composite, ';'?/A" fzr cortinrous
<br />monitoring, etc.)
<br />10. P/here violrtions of permit regeirements arc reposed, ettach a biiefexplanation to c'e:.aibe causa and enrrCr~ vc ao''on,
<br />to be taken, and reference each violation by date.
<br />1 I . If "no discltasgc" accu-s during moritcrie„ pc. iod, cater "Nc T: scharbc" across Perm i n riace : ' da'< c -~-y
<br />]2. Enter N<nne/Titlz e ~rr,.r al FSdCilliY'_ / _zr" c.ith 'Si,;rr~wre r Prima; ! r. ,. i' r '
<br />~;gznt, ""Tzlzphone Nu,nbzr,"aod "Cali" at bottom of farm.
<br />13. Mail signed Report to Office(s) by date(s) specified in permit. Retain copy for your seen-~ s.
<br />14. Mo,>r detailed instructions for use of :his Discb~,;;e .14o~1itcriag R-r;;~t (L:,b't~ .o, ~ r'*_y i : o:~ici~su frcm ,^."°-.c;r)
<br />specified in permit
<br />~~~~~ ~~~~~Il~~
<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 ttuthf~lly can rsult in
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per aay of viola5on,
<br />or by imprisonment for not more than one year, or both.
<br />EPA Form 3320-1 (Rev. 03/99)
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