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<br />Paperwork Reduction Act Notice
<br />Public repoRing burden for this collectioe of information is estimated to vary from a range of 10 hours as m
<br />average per response for some minor facilities, to l10 hours as an average per response for some major facilities,
<br />with [weighted averege for major and minor facilities of l8 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 inforntatiom. Send comments 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 Agzncy, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed at entry of that, information
<br />already preprinted.
<br />2. Enter 'Permi(tee ,Name.3larlirg Address (and facility name/localion, if diSeren[)," "Permit Number," and
<br />"pischnrge Number" where indicated. (A separate form is required for each discharge)
<br />3..Enter lots beginnrng and ending 'S+Jnrrtoring Period" covered by form where indicated.
<br />4. Enter each "Paromete-' as specified in monitoring requirements of permit.
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<br />5. Enter "Sample Sienw,emcnr" data fns each parameter under "Quantify" and "Quality" in units specified in permit.
<br />"Average" a n~tmally ;.rithmeuc acersge (geometric average for bacterial parameters) of all sample measurements
<br />for each parameter cb!aired daring '.bfonrtoring Period"; ':dfnximum" and "tifinimunr" are normally extreme high
<br />and law measurcmzrrts obtained during ".1forr~(orirrg Per;nd." (Note to municipals with secondary treatment
<br />requirement. En+er l0-0av average of :ample mcasurcments under "Average," and enter maximum 7-day average
<br />' of sample measurements obtained during monitoring prioo under ",bfarimurn.
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<br />I b: Enter "Permir,4eyuiremenr" for each pnramder under "Quantity" and "Quality" as specified in permit.
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<br />7. Under ",Vo fix" enter number of sample measurrnenls during monitoring period that exceed maximum (and/or
<br />~: miniruum or 7.day average as appropriate) permit requirement for each parameter. If none, enter "0".
<br />~;;3. Enter "r^regueney oJAnalysis" bn!h as "Sa+nple ,Llees:umenr" (actual frequency of sampling and analysis used
<br />~x ~ tidunng monitoring period) and as "Perrrrr ReyuiremenP' specified in permit. (e.g., Enter "Cons," for continuous
<br />k monitoring, "t/T' (or one day per week, "I.30" for mte day per month, "//90" for one day per quarter, etc.)
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<br />!'~. 3;nter "5'nmple %ype" both as "Sumnl.~ ,!Jeacurentent" (actual sample type used during monitoring period) and as
<br />,; 'Permit Reyviremenr," (e.g., Enter "Groh" fur individual sample, 24HC' for 24-hour composite, "NiA" for
<br />!f~ , ;continuotu monitoring, etc.)
<br />'10. 'Where violaUOns oi' parent regw:emems are reported, a;}ach a brief explanation to describe cause and corrective
<br />actiot+s taken, and reference east; . iolation by date.
<br />li. If "no discharge" occurs durng monitoring pzr iod, c^der "h'r. Drscharge" across form in place of data entry.
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<br />~L: Enter ",\'ameiTitle ojPrincipnl rrecutire O,~crr" wrih "Ggnature oJPrincipn! Executive Officer ojAufhorized
<br />' :4genr," "Telephone Number," and "!"late" at bottom of Corm.
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<br />T3. Mail signed Report to Office(s) by dare(s) specked u. pern~~t. Retarn copy for your records.
<br />~~. More detailed instructrons for use el this DLcn~u-_v..° "fonr:wing Report (DrLtR/ form may be obtained from Office(s)
<br />specified in permit.
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<br />~~, Legal Notice
<br />T'~tie report is required by law (3? U.S.C. ];:8; =-0 C.:.R. ]25.27). Failure to report or failure to repoR truthfully can
<br />r~rtrlt'in civic penalties not to cxez ~d t i(' ~C7 I,er day of violation, ur in criminal penalties not to exceed $25,000 per day
<br />o ~iolhtion, or by imprisonment for ra morn than omz yesr, or by both.
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<br />EF.t`Form 3370-1 (Rev. O8-YS)
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