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aperw ark Reduction Act Notice Public reporting hone average per response facilities, with a w'ei€ reviewing instruction completing and revit Chief, Information F ~'ashin;gton, DC 204 Budge[. Washington, I. If form has been prepr~ted. 2. Enter "Permittee ,humher' where 3. Enter dates begin 4. Enu:r each "Para n for this collection of information is estimated to vary from a range of ] 0 hours as an for some minor facilitier~ to 110 hour,, as :m average per respons . for-some ptajor red average or major art~facili~.~es of 18 hours per t+~spanser ' ding time for searching existing data sotl~es, gath~_rini; turd maintaining the to needed, and sing the ~oll:ction of ini=orinatior., includink~ suggestion for reduci g this burden, to dicy Branch, PM-223, U.S. ]environmental Protect~p Agency; 40 M Street, S.R`. 0; and to the Office of Information and Regulatory Affairs, Office of~Managemetit and )C 24503. - - - ~, GeneralInst~uctions tally completed by preprinting, disregard instruction directed a[ entry of th~u information already re~d9udAt,; A~Idress (and facility name'lucation, if differentl." " Permil.'Vwt~bert" and "Discharge ated. (A separate form is required for each discharge ) and editing ",LloniloringPeriod"covered by form where indicated; ~'" as specified in monitoring requirements o.Fpermi[. ii ~. Enter "Sample Mea urr,~nenr"data for each parameter ender "Qramirti"and Quulin "as specified i permit. "Averog,~" is normally ari[hmeti average (geometric avenge for bacterial parameters) of all sample meastueme tts for each parameter obutirted during onitorino Period"; ".Mnrinurm" and Minimum" are normally extreme high a td low measurements obtained during " nirornrg Period". (Note to tnwticipals with secondan treatment reguiremenL•~Enter 30-day average of sample measure cents tinder "Ar eruge,"and @nier maximum 7-day average of sample measure vents obtained during monitoring period t nder "M1fia6nean.") 6. Enter "Permit Requ~rcmenr"for each parameter under "Quantity"and "Quulim" as specified in pe 7. lJnder. "No E.r" ent r number of sample measurement during monitoring period that exceed maxirr~ttm (and/or minimum or 7-day average as appropriate) permit requirement for each parameter. If none, enter "0". 8. Enter "Frequenct~ Analysis" both as "Sample Measurement" (actual Gequency of sampling an~ analysis used during monitoring period) nd as "Permit Requirement"specified in perrutt. (e.g. Enter "Coat," for contin ous monitoring, "1 /7" for tine day per wee •, "!/30" for on: day per month, "1/90" fat one day per quarter, etc.) 9. Enter "Sample Typ "both as "Sample Measurement" (actual sample type used during monitoring period) and as "Permit Requirement," (e.g Enter "Grab" for individual sample, "24FIC" For 24-hour composite, '~r/A" for continuous monitoring, etc.) I 10. Where violations of permit requirements are reported, attach a brief explanation to describe cause herd corrective actions to be taken, and ref ence each violation by date. II I I. [f "no dischazge" oc ors during monitoring period, enter-"No Discharge" across form in place of date entry. 12. Enter "Nnme/Title ~f Principal Esendive Officer" with "Signature of Principal Executive ~~cer of Authorized Agent. ""Telephone urnher."and 'Date" a[ bottom of form. 13. Mail signed Repoli o Office(s) by date(s) specified in ptSrtnit. Retain copy for your records. 14. More detailed inst c[ions for use of [his Discharge Monitoring Report /DMR) form pray be obtained from Office(s) specified in permit. Legal Notice This report is required 6 law (33 U.S.C. 1 ; l8; 40 C.F.R. 125:27). Failure to report or failure. to report thfully can result in civil penalties no[ [o exc ed '610,000 per day of violation; or in criminal penalties not to exceed $25,00 per day of violation, or by imprisonment for of more than one year, or both. EPA Ferm 3320-1(Re~} 08195) t i