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1~(S'S l•J~ii V~~~.. I~~.':.t~Il ~i1~~~' ~~~ ~~~~ ~~~'v
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<br />PubSc reporting burden for this collection cf im°ormzfon is estimated to vary f-tom a rangy o` 1C hers rs an
<br />zerage per response for some minor faci ities, is 110 hours as an Overage pe response ;:o. soy: ~ r-ajor
<br />fat?lities, with a weighted average for majc: and r:~inor facilities of 1 h !~o,ss per response, isclud` i,; ~irr e''or
<br />reviewing instnictions, seazching existinfi data sow-ces; gathering and maiotai;ling the _'*ta ~e°~ed, rm:;
<br />corpleting and reviewing the collection ; £ in,°ormation, including s:Jggesticn for reduci ~g tits bt~rder., to
<br />Cir~f, Itformation Policy Branch, FU-223, J.S. ~avironmental F.ctcctiort i~gcncy, 4~0.' n~i ~`~c_t, 3 `T/.
<br />\Vashington, D~ 20Afi0; znd to the ^,~ce cf Information and Regulatory Rffai_s, Cilice c'i';Lrn,ge:-en: u-rc
<br />Budget, bVashingtou, D~ 20503.
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<br />I. If form has been partially completed by p:.:.:.inting, disregard instruction circted at ~~iry of ~~°.: inf~rma':on iL-erdy
<br />Preprinted.
<br />2, Eater "Permittee Nome/idailing dddress (~ ~~ facility name/locaiion, if difierect)," " Fzrm[t Nu. ~ ~•," an'_ 'F..rc.'~c.oz
<br />Number" where indicated. (A separate forr ~ is required :or each discharge.)
<br />3. Enter dates L•eginning and editing "i+7n;riJbr' ~ Peri~.d"covered by form where indict red
<br />4. Enter each "Parameter" as specified in mrn c..-sg requirements of gerv,it
<br />5. Enter Sa;aple iileasurement"data icr e_cii ,:aramer:r under "Qua.rtity" any =.~eliry~"cs pccifeas p:.rr.. t `.`r_ age" s
<br />normally arithmetic average (geometr'e av~ ~,;c ;:: bt_cterial pare,-peters) ~ `a'I san•~!c r.eas~!remc ~':. ~~ • esci : _:.mctrr
<br />obtainer du,-ing "I/lonitoring P_-iod"; ^L,..a;;;,;rr^ ._:d idmir,:rrr" aze normally e.tri,.te high tnd .o'., r.tasu:. ~!e-• s
<br />obtained d~-ing "Ivicrtitoring i'eriod". (?`'o:: lc municipal •~ith secondary iTeatmen, re1uirement: ~c.c_ 3C-nay ,c~ro_
<br />of sample measurements under 'Ave~aoe," a9 eater maximum 7-day ave.-age of sa-np ~ measc-: i_ is ot'u-',-!ec: c:u-a;
<br />mon:toring period under "~47aximum.")
<br />5. Enter "Penait Re9uirement"for each pataQ c:er under "~ivantity"and "Qt!ali.ry" as sl,eci3ed is perr t.
<br />7. Under "Na Ex" enter number of sample mcasu,e•neat during monitoring p~cd the' exceed ma::icnu_n (andrr mi rim'lnt
<br />or 7-day average as appropriate) perm%t regiircment for each parameter. If none, enter "0".
<br />8. Ente_ "Fre;uency of Analysis" bath . s "S~ -~n!e 1Lzastvem ,rt" (actual frequency e" sa npling and a~ rlysis usei d,rr:ng
<br />monitoring ge•iod) and as "Permit Req;ri*e,r.~~!t" spcciGed i~ per~rit. (e.g. Enter "Coe!," 'or contineo ~. monlerir _, "I/7'
<br />for one day per wee!c, "1/30" for one c'ay ne month, "!/90" for one day per quarter, e'c.)
<br />9, Enter "Sample Type" both as "Sa,uple Mza. •rerne;:J" (actua: sample type used during m ~aitoring pe_iad) arc as "Per,::iJ
<br />Requirement," (e.g. Enter "Gran" ,or in?ividual sample, "24HC" fo= 24-hour composite, "iv/,.' fo- _oriinuous
<br />monitoring, etc.)
<br />IC. Where violations of permit requirements azc rcgorte:, attach a brief explanation to desenbe cause ~:d corrcc'ive c.tion~
<br />to be taken, and reference eats vio]ation by .ate.
<br />11. If "no discharge" occurs curing monitoring period, enter "No Dischazge" across form in place of da a ..try.
<br />12. Enter "NamPl."itle of Principal Executive Officer" with "Signature of Principe! Executive O,~!cer oy` /.nr„orizec'
<br />Agent, ""Telephone Number,"and "Date" at bottom of form.
<br />13. Mail signed Report to Office(s) by date(s) specified in permit Retain copy for your records.
<br />14. Moro detailed instructions for use of this Gischa:-ge Monitoring Report (D/~1 foam may be obtai.~cd fin:z Cfiicc;s)
<br />specified in permit.
<br />This report is required by law (33 U.S.C. 1318; ~+~ C.F.R. 125.27). Failure to report or fai_urc to report tr.:'Sully car result i`
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to ezcced $25,000 rer day of violation,
<br />or by imprisonment for not more than one yeaz, o: both.
<br />'EFA Force 3320-1 (6tev. 03/99)
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