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Paperwork Reduction Act Notice
<br />Public reporting burden ft>~Ihis collection of information is eat' tad to vary from a range of 10 hours as an
<br />average per response for sor6e,minor facilities, to 110 hours ~ -" stage per response for some major facilities,
<br />with a weighted average 13y,~itjor and minor facilities of is per response, including time for reviewing
<br />instructions, searching eti sources, gathering and maintaining the data needed, and completing and
<br />reviewing the collection ofv lion. Send comments regarding the burdee estimate or any other aspect of
<br />this collection of information, including suggestiow for [educing this burden, to Chief, information Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washin),~ton, DC 20460; end to the
<br />Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
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<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed et entry of that information
<br />.already preprinted.
<br />2. Eater "Permittee Name/1llailing Add~pss (and facility naaiF/location, if diB'ereh[j," "~rmAl lOh11iB"ei,"' 3tf4`t" ~3;ltn.a
<br />"Discharge Number" where indicated. (A separate Corm is required for each discharge.) = '
<br />3. Enter dates beginning and ending Monitoring Persod" covered b} (arm where indicated.
<br />4. Enter each "Parameter" as specked in monitoring requirements of permit.
<br />5. Emer "Sample Aleasureme,u" data for ear,)'f~arame[er under "~anrity" and "Quality" in units specified in permit.
<br />"Average" is nortrtally arithmetic avur(geometrc average or bacterial parameters) of all sample measurements
<br />for each parameter obtained during "Monitoring Period"; "tifazirnum" and "rtilininrum" are normally extreme high
<br />and low measurements obtained during ",tlonitoring Period." (Note to municipals with secondary treaUnent
<br />requirement: Enter 30-day average of sample measurements under "Average," and enter maximum 7day average
<br />oCsample measurements obtained during monitoring period under "hfaximum.'J
<br />6. Enter "Permit Requirement" for each parameter under "Quantity" and "Qunhty" as specified in permit.
<br />7. Under ",Ne Ex" emer number of sample measurntents during monitoring period that exceed maximum (and/or
<br />minimum or 7-day average as appropriate) permit requirement Cor each parameter. If none, enter "0".
<br />8. Enter "Frequency ojAnal ~si.c" both as ."Sample i~leasurrnenP' (actual frequency oC sampling and analysis used
<br />during monitoring period) and as "Pernd!'Reguirenient" specified in permit. (e.g., Enter "Cons," for continuous
<br />monitoring, "//7" for one d:ty per week;"/i30" for one day per month, "//90" for one day per quarter, etc.)
<br />9. Enter "Sample Type" both as ".Sample .lfeasuremenr" (actual sample type used during monitoring period) and as
<br />"Permit Requirement," (e.,., Enter "Grab" for individual sample, "24NC' for 24-hour composite, "N/A" for
<br />continuous monitoring, etc.l
<br />10. Where violations of permit requirements are reported, attach a brief e.Yplanation to describe cause and corrective
<br />„ "~~iun~ rnlcrq ~ reference each violation by date. '
<br />11. If "no discharge" occurs during monitoring period, enter "No Discharge" across form in place of data entry.
<br />12. Enter "Name/f'irle ojPrsncipal Executive Officer" with "Signature ojPrtncipnl Executive OJTcer afAuthorized
<br />Agent," "Telephone Number," and "Dare" a[ bottom o(form.
<br />13. Mail signed Report to Otlicc(s) by date(s) specified in permit. Retain copy for your records.
<br />14. More detailed instructions for use of this Discharge Aloniroring Report (D.41R) form may be obtained from Ofi'ice(s)
<br />specked in permit.
<br />Legal Notice
<br />This report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure [o report truthfully can
<br />result in civil penalties not to eace:d b10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />' EPA Fotm 3320-1 (Rev. 08-95)
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