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Paperwork ]Eteduction 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 facilities,
<br />,i with a weighted average for major and minor facilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining [he data needed, and completing amd
<br />reviewing the collection of information. Send camments regarding the burden estimate or any other aspect of
<br />this collection of information, including suggestions for reducing ibis burden, to Chief, Information Policy
<br />Bramch, PM-223, U.S. Environmental Protection Agency, 40l M Street, SW Washington, DC 20460; and to We
<br />Office of Information and Regulatory Affairs, Office of R4anagememt amd Budget, Washington, DC 20503.
<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 'Permitree ,VameMailing Address (and facility namellocation, if different)," "Permit Number," and
<br />"Discharge Number" N•herc indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and ending "tifonitnrtng Period" covered by form where indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />5. Enter "Sample ,Llea.rurement" data for each parameter under "QunnliN" and "Quality" in units specified in permit.
<br />",overage" is normall}' arithmcuc average (gco.nctric average for ba_teria' parameters) of all sample measurements
<br />For each parameter obtained during ",Llommrmg PerioB'; ".1lasimunr" and "Minimwn" are normally extreme high
<br />and law measurements obtained during "Almvironng Penud." (Vote to municipals nth secondary ve:_tment
<br />requirement Enter 30~ay average of sarnplc mcasurcmcnis under ".overage," and enter maximum 7-day a~•enge
<br />of sample measurements obtained during monitoring period under "afazimurn.
<br />6. Enter "Permit Requirement" for each parameter under "Quantity" and "Quality" as spce~cd in permit.
<br />7. Under "A'n Ex" enter number of sample mea;urmems during monitoring period that exceed maximum (and/or
<br />minimum or 7-da} average as appropriate) pcrn~,it requirement for each pa.~nteter. If none, enter "0".
<br />8. Enter "Frequency ojAnalysis" both as ".Semple ,ileu~vrment" (actual frequency of sampling and analysis used
<br />during monitoring period) and as "Permit Regwrement" specified in permit. (e.g., Enter "font," for conunuotts
<br />monitoring, "!%7" for one day per week, "1.30" .or one day per month, "//90" for one dtry per quarter, etc.)
<br />9. Enter ".Sample Type" both as "Sample Aleasur.•ntent" (actual sample [}pc used during monitoring period) and as
<br />"Permit Requirement," (e.g., Enter "Grab" for individual sample, "1dHC' for 23-hour composite, "t'I/A" for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements arc reported, attach a brief explanation to describe cause and corrective
<br />actions taken, and reference each violation b}' dote.
<br />11. L`"no discharge" occurs during monitoring period, enter "No Discharge" across form in place of data entry.
<br />12. Enter "Name/I'itle ojPrincipal Executive O~~:er" vv~th "Signature ojPrincipnl Executive Officer oj.4uihorized
<br />Agent," "Telephone A'umber," and "Date" at boV'.om of form.
<br />13. Mail signed Report [o Ot3ice(s) by date(s) specified in permit. Retain copy Cor your records.
<br />14. More detailed instructions for use of [his Discharge A-foniroring Report (DMRJ form may be obtained from O@ice(s)
<br />specsed in permit.
<br />Legal Notice
<br />1Lis 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 $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 Forto 3320-1 (Rev. 08-95)
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