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Paperwork Reduction Act Notice
<br />Ppblic reporting burden for this collection of information is estimated to vary from a range of 10 hours as an
<br />airmiage per response for some rmnor farililies, to l10 hours as an average per response for some major facilities,
<br />with a weighted average for major and minor facilities of 18_4aurs.per response, including time for revigL,w4tg
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<br />instructions, searching existing data sources, gathenng and main~aining [he data needed, and completin ,nil
<br />reviewing the wlfection of information. Send comments regarding the burden estimate or any other.lsQof
<br />thi's collection of information, including suggestions for reducing this burden, to Chief, Information Policy
<br />~~h, PM-223, U.S. Eoviroal'hrental Protection Agan..,, 401 M Street, SW Washington, DC 20460; end to the
<br />Ofli~e oflnformation and Regulatory ,4ffai"s, Office of Afanxgement and Budget, Washington, DC 20503.
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<br />;•, General Instructions
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<br />f d. iP form has been psrtislly c~mpletul by prepri~lir:o, dismgard instructions directed at entry of that information
<br />', :skteady Preprinted. '.
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<br />- ~ i2'. koter "Prrmittec Nae:eibfaiNrg Addreas (and f ciliry munellocation, J differenQ," "Permit Number," and
<br />Disch,xye .Nun:her" where indicated. (A separate form is regwred for each discharge.)
<br />li3i $n[er~d:.tes beginning and endu~g ".vnnuoring Period" cocee.d by form where indicated.
<br />~4,.Enter each "Parar:etei' as spc-stied in rsu; storing requirements of permit.
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<br />5, Enter ".rumple.:rzanaremenP' c:a: , ~nr eacn parameter under "~'uanlity" and "Quality" in units specified in permit.
<br />' gverr,g, " is normally ari(hmenc : -,age (gr~r.;et~c ::vemge far bacterial parameters) of all sample measurements
<br />{, for e<~sh pararnetc; obtained drr;.~s "t;ur::r.rring Prrior."', ".lfaximurn" aril "hhnimum" are normally e>,treme high
<br />' and low measurements obtained dnnng ".tlonduring Per: e:?.' (Note to municipals ssilh secondary treatment
<br />' requirement: "c:ei '0-ray asua::, n,` ~,:rtole mcasutemenn under "Avernge," and enter maximum 7-day average
<br />j of sample measurements ebtains;d 6urirg monitoring period render "Alazimum.
<br />b. Enter "Perini! .':c,;,rirrment" fit ca,-'t para:r.,,:.r under' iluaniiry" ar+d "Quality" as specified in permit
<br />t7, Under ""to F1" crier number cf .ounple n+eavr .:cots during monitoring period that exceed maximum (and/or
<br />` minimum of ~ d;,~ average as appr..;,; ate) pe, ~ .it re ;uiremcnt far each parameter. ff none, enter "0".
<br />~. Enter "trcyv~..-:,~ n/'.L~nis•ss" t.r,~l:.+s ".)'ample ~l.•awnro:!" (acn+al Crrqucr:y of sampling and analysis used
<br />during monrtcra~ per,ndl ,nil a: ^{'rr.nil kryu~rN:aen!" ~,cei!iod in permit. (e g., Enter "Cool," for continuous
<br />;_ monitoring, "r ~" far i,nc dsy per •..cek, "; ., B" for one day ~~cr mouth, ";/90" for one day per quarter, etc.)
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<br />~. Enter "tirmr•'• i:r,'F" both a; "5,.,.:~.t•~ t,r~,::rtc,.ru" (ac'oal sample type used during monitoring period) and as
<br />"Perrnu R~yurrrnenl," (e.g., En..: ' ;rob" !u. +~~dividuai sample, "2JHC" (or 24-hour composite, "NSA" for
<br />.untinuoas monitoring, ac )
<br />t ',R'here ~ iola:iens of permit regwrrm^nts are :cponrd, attach a brief explanation to describe cause and corrective
<br />+ actions taken, and reference each violation by date.
<br />. If "no discharge" occurs during mrmi!~r.ng pcr,od, enter "h'o Discharge" across form in place of data entry.
<br />§(~, Enter ",1'amr/I'itfe oJPrincipaf F'.ta:utive OJ~~er" with ".tiignature ajPrincipaf Executive Officer ojAulhorized
<br />~ ~ Agent," "Telephone Number," and "i7ale" at batura .,f loon.
<br />13; Mail signed Report to Office(s) by date(s) specified in permit. Retain copy for your records.
<br />~' More detailed instructions for use of this Dscha-,¢^!.fonilonng Report nbfR) form may be obtained from Office(s)
<br />'r specified ir. pertnit.
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<br />I ,ega! Notice
<br />r- deport is requ~n~d by law (33 U.S.C L1R; i0 C.F.Is. 125.27;. Failure to report or failure to report truthfully can
<br />t t4 cavil penalties not to exceed S14,OW per day nt •:,rlatioo; oe in criminal penalties not to exceed 525,000 per day
<br />n ~iotptioa, nr by impnsonment for no: more Gran one /ear, or by both.
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<br />EPA 1?arvt 33in ] (7iev. U8-YS)
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