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Fa~er~ori~ . L:~~~w~.or~ Act Noti(-~:,,
<br />Public reporting burden for this col]ection of information is estimated to vary from a range of ]0 hours as an
<br />average per response for some minor facilities, 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 instuctions, searching 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 />f.~eneral Instructions
<br />I. If form has been partially completed by preprinting, disregazd instruction directed at entry of that information already
<br />preprinted.
<br />2. Enter "Fzrmitt~e NamzhYlai/ing Address (and facility name location, if different)," " Fzrmit A'umEer;' and "Gischrngz
<br />Numhzr' where indicated. (A separate form is required for each discharge)
<br />3. Enter dates beginning and editing "Monitoring Fzrir,„y"covered by form where indicated.
<br />4. Enter each °F.IYalnc'tJP" as specified in monitoring requirements of permit.
<br />5. Hnter "Samp/~ ni_aSUraaau"data for each parameter wtdcr "[.u~n[iry"and Quality" as specified i n permit. "Av-~ragz" is
<br />norrrnally arithmetic average (geometric average far hcctcrial pammcie!~) of all sample mcc suremcrts for each parameter
<br />obtained during ",Ll:;iir.ri;;g !'s;r,y"; "d•~'asirvm;r" and ;~liui;,rrun" arc no+m. ily rstrcine high and lo~.v mcasuro.aeots
<br />obta'vned Jeri:g '?.( ni/~„ i,,e P~, i-.~". (1~etc to r,ir.icinz,ls raith seccndr.ry trca!menl iaquirer.c~;t: rrtc; 30-dzy eti.:raga
<br />of ss,nl,'c meascremz~ L under ~Iv~,l,;~,"aml en:ei -'cx~r',a:. 7-day at~raga cf sum;'c noasarcn_,trs nbtaincd d1inU
<br />moniiutingperiod under'SLia:nawiz")
<br />6. F.n:er'Y•.,.rit it •:;nilrn!_;lr" nor each narar~r,~r uadc: "fir,;:! /r"..i~'J ,,,;,,~lf~'"as specified t ncrrr~:.
<br />7. l; mac, "i/: Fr" ent,-:.,urabe- o^sr~ple me,~~ucrtnr~ Cr., i~ ° pro +~ln ;~,t~ ~,_:~nc: teat .,.:'. ~d ~~air ream (aidlnr min~mnm
<br />c-7 ~aya~c-etc;s..p~:ronriatc~pcrmitrc.;!r:~..mr.,t ~~!eachparan,e~._r.'fnone,entc-"0"
<br />8. I'....: "~•/ ,:. ,;r i ~ f,'aat,,.vi~"roGt as "S: -r..l'..•/. _,. ,. ' (::~t_~' ,,:qo~: c;, r•^~ar,~ ,li g ar,•~ ana~y~is .std dvr.n~
<br />r ~cn rturn~ peg;nc) ~ .. cs " ,;.,i! Rr:y •i/~ ,,, ~m" snr~ ~G.J :n f•°r~, ;c.g. i'r!cr " „ ~:rr conc~:uoss m mi,uiino, "; /7"
<br />for rnr day p;Y •., _u':.~ "1/30 in, rent dap rcr month, '; io0" fo ant dny per quarl'_~, el~c.)
<br />S. -:n . - "S.•/^t r= TJ1 bu li r.a ".C,./,/!„ i'..,.~s, _i.. , . ct,,i wr,.pi ,~,n- . .d during !nunitorin` retried) and as "f_n,~l:
<br />h •,~n%+v,•z:a" (a.~. ?'~t:.r ";,.-at" Fur indi~~i~::~l .~~:, ~!_, "~.ri ~~" fnr 24-:~ci cnmrasitc, •`.%r." fnr canr~rccrs
<br />monitorng, etc.)
<br />10. ~!/;tc,c viohuti.~as of permit rcc;uiremots ,rc ~oy;cic.', rrtac't :. c isf c.¢n'nt~tio~ to c~~cribc c. ~,c rod corrcc~vc ~ctioa;
<br />to b.: talccn, sod reference cacti violation by dale.
<br />'. !. 7"`cu dischargd' o::curs dv-`rg nun,bnng prrio5, c ;._! ""o'Ji~d+ar~." cross fnnn in relate attar, miry.
<br />12. En cr "Aran, z/Titi_ uj l~rire~i} a! b'c~. u[i•.e r~%._ !~•it'n ".S;~n~4 rr ,,f h) 4a -y ~r Fz ~.v!iv: rifji.vr -,j rfuti.•.r~rJ
<br />~grur, ""Ty!dp;s.tr Nurt! ~sr," and "Cure" at bottom of romr.
<br />13. tilail signed 3epcri [o OC,ic-e(s) by datu(s) specified ~n Hermit. Retain copy for your records.
<br />14. ~Aorc detailed instructions fo- use of this Lis.Sarbe ..;o:~ilo/ i,ro R7:,-[ (C%+•>7~ 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 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 not more than one year, or both.
<br />EPA Form 33211-1(Rev. 03199)
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