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- Paperwork Reduction Act Notice
<br />Public rt:porting burden for this collection of information is estimated to vary from a range of l0 hours as en
<br />average per response for some minor facilities, to 110 hours as an average per response for some major facilities,
<br />with a weighted average for major and minor facilities of l8 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
<br />reviewing the collection of information. Send comments regarding the burden estimate or any other aspefrt of
<br />this collection of information, including suggestions fur reducing this burden, to Chief, Information Policy
<br />Branch, PM-223, U.S. Envrronnrental Protection Agency, 401 M Street, SW Washington, DC 20460; end to the
<br />Offic~'of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />li lf,form has been partially completed by preprinting, disregard instructions direcled-at entry of that information
<br />alieady preprinted.
<br />2. Eoler ".°erm!rtee Name%ifniling Rddre.cs (and facility name/Ioca0on, if different)," "Permit Number," and
<br />". DiscJra~;gr A'unche." where indicated. (A separate torte is required for each discharge.)
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<br />3: Enter dates beginning and ending Moniroriug Period" covered by form where indicated.
<br />4: Enter each "Parameter" as specified in monitoring requirements of permit.
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<br />{~5: $nteY "Sample df"nsurement" data far each parameter under "Quantty" and "Quality" in units specified in permit.
<br />E I •, "Averng~' is nnrmalh- arithmetic n•cmge Geometric avemge for bacterial parameters) of all sample measurements
<br />for each pa:an,eter obtained duriag'klon:iormg Perrod"; "Afaximu~u" and "4finirrwm" are normally extreme high
<br />-~; and low measuremems obtained during ';tlcnimrir,g Ferrod." (Nate to municipals with secondary Vestment
<br />requirement Gr.ICr 30rfav avemge of sarr~~le measurements under "Average," and enter maximum 7-day avemge
<br />of sample measurements ohtaincd during m:ailoring period under ",ifaximwn.
<br />b: Entec~".permd Requirement" for each para„x;cr under "Quantity" and "Qualify" as specified in permit.
<br />7; Under "vo 1•'r" enter number of smrrple measun~t~nts during monitoring period that exceed maximum (and/or
<br />minimum or 7-day average as apfrcpriare) pcnnit requirement for each parameter. >f none, enter "0".
<br />~, Enter "ficq!.encv !,~ .Aralvr,c' bash ;.~ "Anmple .1lr,a.ttrrmen(" (achtal frequenry of sampling and analysis used
<br />;; during momtn!irig period) ar~d as 'Perrnir Regcurrmeni" specified in permit. (e.g., Enter "Coot,' for continuous
<br />rnonitorit:g, "1.'7" fur one day per "~ aek, "1~3^" for o;,e day per momh, ' 1/90" for one day per quarter, etc.)
<br />Enter "S'ample l ype" both as "Sou!p!e ,1:eas:~'emeuP' (actaal sample type used during monitoring period) and as
<br />"Permit Requirement," (e.g., Etter " ,.at•" lo: individ!tal sample, ":dNC' for 24-hour composite, "N/A" for
<br />continuous moaitoring, etc.)
<br />'Where violatioru of permit requiremcats arc reported, attach a brief explanation to describe cause and corrective
<br />actions taken, and reference each violation by date.
<br />Jf "no discharge" occurs during monitoring period, enter "h'o Discharge" across form in place of data entry.
<br />Enter ",'~'ame/I'itle ajPrincipa! Executive Omar" with "Signature ojPrincipal Executive Officer ojAuthorized
<br />Agent," "Telephone Number," and "Dare` at bottom of form.
<br />. Mail signed Report to Office(s) by date(s) specified in perntit. Retain copy for your rewrds.
<br />~4. More deLilled instructions for use cf this D..+cha; ge bforriloring Repot! (DMRJ form may be obtained from Office(s)
<br />r specified in permit.
<br />~# ~,ebal Notice
<br />T ~ r; is required b~ law (33 U.S.C. 1?l8; 4p C F.R. 125.27). Failure to report or failure to report truthfully can
<br />re t Ar rival penalties not to exceed $10,000 per uay n: violation; or in criminal penalties not to exceed 525,000 per day
<br />0 oFAtien, ur by imprisonment for not more than one year, or by both.
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<br />E)~1y'Form 3320-1 (Rev. 08-v5)
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