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Paperwork Reduction Act Notice
<br />Public repoRing burden for this collection of information is estimated to vary from a range of 10 hours as an
<br />average per response for soiree minor facilities, to 110 hours as an average per response for some major facilities,
<br />with a weighted average for major and minor facilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
<br />reviewing the collection of information. Send comments regarding the burd~:n estrma[e or any other aspect of
<br />this collection of information, including suggestions for reducing this 6urdeo, to Chief, Information Policy
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW \Vashington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of t<1anagzment and Budgzt, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially complct~i by preprinting, disregard instructions directed at entry of that inforaulion
<br />already preprinted.
<br />2. Enter 'Permi((ee A'arnt'Uailmg Addrecc (and facility ruarneAocauon, if different)," "Permit Number," and
<br />"Discharge A'unrber" vvhrre mdicatcd. (A separate form is required for each discharge)
<br />3. Enter dates beginning ani ending ".t,'nni(nring Prriod" covered by (orm where Indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit
<br />5. Enter "Smnple Sfracuremenr" data for each parameter under "Quamirv' and "Quohh" in units specked in permit.
<br />":I rernge" is normally arithmetic average (geometric average for bacterial parameters) of all sample measurements
<br />for each paramdcr obtaiacd during ",11aru(orirrg Penod"; "9fa.rirnunr" and "SLnimunr" are normally extreme high
<br />and low measurements oM,rincd during ",tfnnuurw Perrod." (Note to municipals with secondary treatment
<br />requiremenC Enter 30-dav average of sample measurements under "Average," and enter maximum 7-day average
<br />of sample measurements obtained during monitoring period under ",Lfaxunum.')
<br />6. Enter "Penner RequrrernenP' for each parameter under "Quamifv" and "Qualt(v" as specified in permit.
<br />7. Under ",'Jo Ex" enter member of sample mcasurmcnts during monitoring period that exceed maximum (and/or
<br />minimum or 7-day average as appropriate) permit rcgnirement for each parameter. If none, enter "0".
<br />8. Enter "Frequency oj.4nah:cis" both as ".1'mnpie .4/emunnen(" (actual frequency of sampling and analysis used
<br />during monitoring penod) and as "Fernier Requirement" specified in pcrmn. (e.g., Enter "Coot," for continuous
<br />monitoring, "I;7" for ores d:n per week, "1 30" for one day per month, "1 90" for one day per quaver, etc.)
<br />9. Enter "Sample Ttpe" bosh as "S'nmple Sfencuremenr" (actual sample t}ye used during monitoring period) and as
<br />"Permit Requirement," le.g.. Eider "Grab" for individual sample, "?4f/C" for 24-hour composite, "h'%A" for
<br />conunuotu monitoring, sic.)
<br />10. Where violations of perntit requirements arc reported, attach a brief e.~planation to describe cause and corrective
<br />actions taken, and refcrccce each violation by date.
<br />11. If "no discharge" occurs during monitoring period enter ",Vo Discharge" across form in place of data entry.
<br />12. Enter ",'Vame./fi(le ojPnncrpa! Executive Officer" with "Signature ojPrincipnl Executive Officer ojAurhorized
<br />Agen(," "Telephone A'umher," and "Date" a[ bottom of form.
<br />13. Mail signed Repoli [o Ot7ice(s) by date(s) specified in permit. Retain copy for your records.
<br />14. More detailed instructions for use of this Discharge ,1 foni(aring Report (DAfR) 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. 125.27). Failure to repoR or failure to report truthfully can
<br />result in civil penalties not to exceed S 10,000 per day of violation; or in criminal penalties not to exceed 525,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />EP'A Form 3720-1 (Rev. OS-95)
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