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GENERAL INSTRUCTIONS <br />I. I( form has been partially completed by preprinting, disregard instructions directeJ at entry of th:d information :JrcaJv preprinted. <br />_. Enter "PERAIITTEE N.4MF./HAILING ADDRESS land facility name/location, if JiHern U,` "PER AfIT NUM HF R:' :mJ "DISCHARGE <br />NUMBER" where indicated. 1.4 separate form is required for each discharge.) <br />3. Fnler dales beginning anJ ending "MONITORING PERIOD" covered by form where indicated. <br />1. Enter each "PAR.4 h1ETER" as specified in monitoring requirements of permit. <br />5. Enter "SAMPLE MEASUREMENT" data (or each parameter under'QUANTITY" anJ "QUALITY" in units specific) in permit. <br />"AVERAGE" is normally arithmetic aeera ge Igcumel ric average for hacterial paramelersl of all sample measurements for cech parameter <br />oMaineJ Juring "MONITORING PERIOD." "A1:\X IAtUM" anJ "MINIMUM1I" are norm:Jly extreme high anJ low measarentems <br />obtaineJ Juring "MONITORING PERIOD." INOTI? to municipals wish seconJary treatment requirement. enter 3(I-Jay average of sample <br />measurements under "AVERAGE" anJ enter m:(ximum 7-Jay average of sample measurements obtained during monitoring perioJ under <br />"h1.4XIMUM". <br />6. Enter "PERMIT REQUIREMENT" for each parameter under "QUANTITY" and "QUAI ITl"' as specifieJ in permit. <br />7. Under "N O. EX" enter number of sample measurements During monitoring period that exceed maximum (nnd/or minimum or 7 day <br />average as appropriate) permit rcyuirement (or each parameter. If none, enter "0". <br />8. Enter "FREQUENCY OF ANALYSIS" both as "SA M1IPI-E MEASUREMENT" factual frequency of sampling and analysis use) Juring <br />monitoring period) and as "PERMIT REQUIREMENT" specified in permit (e.g., Enter "CONT." far continuous monitoring, <br />"I /7" (or one day per week. "I/30" for one Jay per month, "I/90" for one day per quarter, etc.) <br />9. Enter "SAMPLE. TYPE" both as "SAMPLE MEASUREMENT" factual sample type used during monitoring perioJ) and as <br />"PERMIT REQUIREMENT." le.g., Enter "GRAB" for individual sample, "24HC" for ?~-hour composite, "N/A" (or continuous <br />monitoring, etc.) <br />(l8tll! 3tl3H Ol0l1 <br />10. WHERE VIOLATIONS OF PERMIT REQUIREMENTS ARE REPORTED. ATTACH A BRIEF EXPLANATION TO DESCRIBE <br />CAUSE AND CORRECTIVE: ACTIONS TAKEN. REFERENCE EACH VIOLATION BY DATE. <br />I I. If "no discharge" occurs during monitoring period, enter "NO DISCHARGE" across form in place of data entry. <br />12. Enter "NAME/TITLE OF PRINCIPAI. EXECUTIVE OFFICER" with "SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />AUTHORIZED AGENT." "TELEPHONE NUMBER" and "DATE" at bottom of (orm. <br />13. Mail signed Report to Office(s) by date(s) specified in permit. Retain copy for your records. <br />14. More detailed instructions for use of this DISCHARGE MONITORING REPORT (DMR) form may be obtained from Office(s) <br />specified in permit. <br />LEGAL NOTICE <br />This report is required by law (33 U.S.C. 1318; 40 C.F.R. 122.22). Failure to report or failure to report truthfully can result in civil penalties no[ <br />to exceed 510,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation, or by imprisonment for not more than <br />one year, or by both, <br />ONOJ38 3tl3H OIOd <br />3213 H <br />dWV1S <br />3~tlld <br />Otl1Nl 3tl3H OIOj <br />~' ~ ~ ~ . 3213H 31dtl15 <br />