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I~~~.-:~~rvvork Reduction Act Notice
<br />Public reporting burden for this collection of information is estimated to vary from a range of 10 hours as an
<br />average per response for some minor faci]ities, to 110 hours as an average per response for some major
<br />facilities, with a weighted average for major and minor facilities of 18 hours per response, including time for
<br />reviewing instructions, seazching existing data sources, gathering and maintaining the data needed, and
<br />completing and reviewing the collection of information, including suggestion for reducing this burden, to
<br />Chief, Information Policy Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, S.W.
<br />Washington, DC 20460; and to the Office of Information and Regulatory Affairs, Office of Management and
<br />Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instruction directed at entry of that information already
<br />preprinted.
<br />2. Enter "Permitlea Name%Noiling Adlress (and facility nameAocation, if different)," " Perini! 1Vumher," and "Pischargz
<br />Numh~r" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and editing "Monil~,ring Period"covered by form where indicated.
<br />4. Enter ea.'t "Pararnrlu "as specified in monitoring requirements of permit.
<br />5. F.nte "S~~ rpl~ ,L;~ Jsvr~,;,znr" data fcr each parameter under "~iuawtity" and ~ualih~" as sncciftcd in pemit. "Avtrlae" is
<br />nonnzlly ar'inmetic areragc (gcoruttric at crage Cor bacteral pammetcrs) of all sample measurements For each pammcter
<br />obtained dui ., ";r,'•,nir%-ring P~rf;J"; ",lllzin+run" znd ,L.7nimnm" are normally c::Gcmc high. and low measurcrnenrs
<br />obtained curing ";J•.u 6,: my F_,i~.J". (P:ote to rnw,icipals pith secondary trcatmrnl r-quir~rrtcnt: linter 30-day ave,ngu
<br />of :r-nine mc-sc~emc;.ts u~Per "!~'-,~~,;:,"and enter n,a~<;count 7-day avc ~gc of se~n;Ju mcasurcmcnis obtained during
<br />monitoring period under "iviaximmn.")
<br />O. r.n`~.f ,1.'Gij!/Z,7PLl'gi~:~l"`o~eachparamci~:-undo: "~,r,,,nlih•"and";.r,a/ity"asspccilicdin ~°rnit.
<br />7. C;dzi "7~. Gr" entr numbs ors2nplc mcr~S Urcmcn~. ciwing moaim-in~ period N-a csceed mar:imum (anrL'or min murn
<br />or 7-d y u;ert~c rs epprop-i,~c) nc~it regrdr.:mcnl ro-each parameter. If none, enter "0".
<br />fl. =n: •' "F,; ;r,ar ~, .j .;n ,!t.,'~"but't c. ".5 ,.,; '~ ,1:', ~c~n -,n_n!" (actual Gcyucncy ,-i sa~tplicg and analysis tscd during
<br />man~te~~,g per'oc}:no zs "P ,,~„r%, k_;nir,rn:nr"snec~fied in pcnnil. (c.g. Gn(cr "..•.a!,"for cor(htuous mar.ituring "!/7„
<br />Cot nnc G: p•-: ,rae'a, "1/30" fog one d1y per mnnfl~, "!/90" for one day per quarter, etc.)
<br />~, r'n+cr ".S s] /• T ~ ."burn rs "Sa,n/ l.• i.'-a,r,,a,;;',,;"(actual sample type used curicq mor»bring period) a :r; as ".'.r„,ir
<br />/-..~r'b;~;;rtr{" (e.g. Tarter "Cr,.l" for individual ~arnplc, "741/" fa' 24-1-nur composite, 'SV/f." for com'nuacs
<br />monitoring, etc.)
<br />10. C"terc vinhtiuns of f~crmrt requirements arc reported, ^(tach a brief cxplanaiion to d_scribc causa and corrective ~-:icnc
<br />to be take, and reference each violation by date.
<br />l 1. I"'no discheryo" recurs derirg monitoring period, entry "No Discharge" across form in place of data enip'.
<br />12. F,n;cr "itS,nJTi(1 ~ ;~ ,'r~,t;:i1 .l F,x~ ~uli,~d Ofj'~ -•r" v<ith "Siy'.ro!,rrz r f Prin:i~,ol F_r_.utn e riffi_a rf Au+;r•,; c_J
<br />A~rnl, ""T~ laFdr ~r. r Arrrm! ~, ; "and "Gala " at bottom of form.
<br />13. Mail signed :cpori to OrGcc'(s) by da~~(s) specified in permit. Retain copy for your records.
<br />14. yfore detailed instructions for use of this Gis~ha+gz L1'.nita-brg R_E•,rt (['tif1~ form may be obtained from Office(s)
<br />specified in permit.
<br />Legal Notice
<br />This n°port is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure to report truthfully can result in
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation,
<br />or by imprisonment for oot more than one year, or both.
<br />EPA Fotw 3320-1 (Rev. 03/99)
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