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Paperwork Reduction Act N
<br />Public reporting burden for Wis collection of information isrstimated to vary from a range of 10 hours az m
<br />Y~irnge per response for some minor facilities, to I10 hours as +n averege per response for some major facilities,
<br />~'th' a weighted averege for major and minor facilities of 18:bours per response, including time for reviewing
<br />~Slnictions, searching existing data sources, gatheringl~ maintaining the data needed, and completing and
<br />reviewing the wllectioo of information. Send commen'Es regarding the burden estimate or any other aspect of
<br />this collection of information, including suggestions for reducing this burden, to Chief, Information. Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washingtoh, DC 20460; end to the
<br />Offrce of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503. `
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<br />- General Instructions
<br />~~l form gas'been partially completed by preprinting, disregud instructions directed at entry of that information
<br />hN e~,dy Preprinted.
<br />{, ~~ _
<br />ter 'Permittee Name/Mai/ing Address (and facility namellocation, if di&erent)," "Permit Number," and
<br />(- Discharge Number" where indiq[ed. ~A separate form is required for each discharge)
<br />}~~rtten dates beginning and ending''~t`son/toring Period" covered by form where indicated.
<br />~'1 '
<br />'j4~. ~nter each "Parameter" as specified in monitoring requirements of pcrmil. ;
<br />+:J'
<br />~5; Enter "Sample Measurement" data for each parameter under "Quantify" and "Quality" in units specified in permit.
<br />~" ` "Average" is normally arithmetic average (geomeUic average for bacterial parameters) of all sample measurements
<br />.for each parameter obtained during "Monitoring Period"; "Maximum" and "Minimum" are normally extreme high
<br />and low measurements obtained during "Monitoring Period." (Note to municipals with secondary treatment
<br />- ,requirement' Enter 30-day average of sample measucements under "Average," and enter maximum 7~ay average
<br />~~ of sagrpld'measurements obtained during monitoring perod under "d4arin+um.
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<br />,~ ~tller "Permit RequiremenP' for each pazameter under "Quantity" and "Quality" as specified in permit.
<br />4 ~ '' kk
<br />~y~'~'ndeT "No Fx" enter number of sample meastrrntents during monitoring period that exceed maximum (and/or
<br />~';;; 1dt}tit(tum or 7-dey average as appropriate) permit requirement for each parameter. If none, enter "0".
<br />44ff ntCr 'Frequency ojAnnlysis" both as "Sample Measurment" (actual frequenry of sampling and analysis used
<br />1~~riiig monitoring period) and as "Perini! RequirernenP' specked in permit. (e.g., Enter "Coot," for continuous
<br />~~ ~ltottitoring, "!/T' for one day per week, "1/30" for oneday per month, "1/90" for one day per quarter, elcJ
<br />a
<br />Eller "Sgrrlple Type" both as "Sample Measurement" (actual sample type used during monitoring period) and as
<br />~entilit Requirement," (e.g., Enter "Grab" for individual sample, 14HC' for 24-hour composite, "N/A" for
<br />r Continuous monitoring, etc.)
<br />'.
<br />Whati: violations of permit requirements are reported, attach a brief explanation to describe cause and corrective
<br />~~ctions taken, and reference each violation by date.
<br />~. If "no discharge" occurs during monitoring period, enter "No Discharge" across form in place of data emry.
<br />)toter "Name/Title ojPrincipn! Executive Officer" with "Signature ojPrincipal Executive Officer oJAulhorized
<br />:Agent," "Telephone Number," and "Date" at bottom of form.
<br />Mail signed Report [o Ogce(s) by date(s) specified in pemtit. Retain mpy for your records.
<br />More detailed instructions for use of this Discharge Monitoring Report (DMR) form may be obtained from 06rce(s)
<br />specked in permit.
<br />Legal Notice
<br />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 />~. in civil penalties not to exceed 510,000 per day of violation; or in criminal penalties'not to exceed S25,000 per day
<br />pf{ttion, or by imprisonment for not more than one year, or by both.
<br />3320-1 (Rev. 08-95)
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