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Paperwork 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 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 instructions, 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 />general Instructions
<br />1. If form has been partially completed by preprinting, disregazd instruction directed at entry of that information aheady
<br />preprinted.
<br />2. Enter "Permittee Name/+tlailing Address (and facility name location, if different)," " Pzrmit Number," and "Grschsrge
<br />Number" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and editing "Monitoring Period" covered by form where indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />5. Enter "S,~rnpL b~l~asunrnent"data for each parameter under "Quan/ity" and Quality" as specified in permit. Avarage" is
<br />normally aritlunetic avcage (geometric average for bact_rial parameters) of all sample measurements fcr each parameter
<br />ob~ained during "A~~ni[aing Period"; "rYLsrimurn" and lfi;r,.nrm" azt normally extreme hig;r and low measurement;
<br />obtained during "l•Isrritorirrg Period". (Note to municipz's ~.+iL'r secondary irecur_nt rtnuin_ment: Enter 30-day avera~c
<br />of sample measurements under "Avzraga,"and en~cr ~;ia.imrT 7-rL_y : vc: rge of sr~ple mess ~rcmenL obtained d ir:-~
<br />monitori og period under "rl.aximrrm. ")
<br />v. En:cr i°Cn1't~ 2.Itu/_'A1Pn("for each pazametci and "1n_~;,tih,•" r :~ "r%v~lity" as specifie2 in ferrri~.
<br />7. Ur•._, "T+v F.-" toter ^umber ofsample mesore~:r ~' do-ir;,• marilc,- ~„ .~r,:d Cm: c~ ceea mrx mem (ar,elar mini-: n
<br />or 7-day aver~gc as appropriate) permit rcquircmer ~ fur ca~~r pr ~~enet:. ?f none, c~r_r "0".
<br />°,. L'nter "F',-.~y,ra;;y of Arr~lysis" both as "Sorry l: 1:' ,~ •. _„i •, r" (ac Y~~l fngt^o; • rf r- ,ipl'nII c rd ana'ysis used [ia ri ~,~
<br />manitorinU period) and as "Pe,~ni! Regrd;z:rat:"spe::ficd in pcTnit. (c.;,. "=rtcr ".., ;{" for continuo~~ monitoring, "J,7"
<br />for one day per wok, "1/30" for one day pe.- mnnl;i, "//90" fcr one c;;.y p_r qua-ter, etc.)
<br />9. ,°.nter "S nnple TIFa" both as "Sanr~da i>iz~~r~re;,ur •" (;.ttual sample t;•pe used dur n~ monitoring period) and as ""_,;,ri;
<br />R_;ui•~eur:,d," (e.g. Enter "v'r.:h" for inc;ividu~l szr,gile, '7dif"' fur 2~-hcur camposite, 'P//A" for continuous
<br />monitoring, etc.)
<br />10. ~',Rrer violations of permit requirements arc r~porteri, rt<ech a b-icfc:n'.aaat4in in dcscrib~ cause and corrective acti:;ns
<br />to be taken, and reference each violation by date.
<br />11. Tf"no discharge" ocew-s during monitoring perod, en:_r'^:o Cae': crg~" cross fo n in place of data e~'S;•.
<br />]2. Sn[er 'Name/Titlz of Principal Fr~_vtive Gf.-a~" r;'ill "Sido»•:c~„• of Prin.:y.l fr~_zaira G~ •ar oj' arrlh-,~-1-~ l
<br />Agent, ""Talaphone Number, "and "Gore" at bottom of form.
<br />13.:v.ai1 signed Reporl to Office(s) by date(s) specified i^ pt: tit. Rct<in copy for yoe recorus.
<br />14. A4ore detailed instructions for use of this Dis~harK~ ;v; ,nit:.rirrS R ; ,;~ (/'; .R) ;o ~n mry be obtained from C~~.cc(,;
<br />specified in permit.
<br />o
<br />~~c_~.~
<br />This report is requved by law (33 U.S.C. 13l II; 40 C.P.R. 125.27). Failure to report or failure to report truthfully can result itr
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violaLio,r,
<br />or by imprisonment for not more than one year, or both.
<br />EPA Form 3320.1 (Rev. 03/99)
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