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GENERAI. INSTRUCTIONS <br />I. If form has been partially completed by preprinting, disregard instrucions directed nt emry of that information aln•adv preprinted. <br />?. Enter "PERMITTEE NAME/MAILING ADDRESS (and facility name; loc;dion, if di Orren U." "PER h11T NUM tlER," ;ind "DISCHARGE <br />NUh1BER" where indicated. to separate (arm is required for each discharge.) <br />3. Enter dates beginning and ending "MONITORING PERIOD" covered by form where indicated. <br />4. Enter each "PARAMETER" as specified in monitoring requirements of permit. <br />5. Enter "SAMPLE MEASUREMENT" data for each parameter under 'QU.ANTITI"' anJ "QUALITY" in units specified in permit. <br />"AVER.AGE" is normally arithmetic average (gromet tie average for bacterial parameters) of all sample measurements for rarh parameter <br />obtained during "h10NITORING PERIOD." "MAXIAfUM" and "MINIMUM" are normally extreme high and low measurements <br />obtained during "MONITORING PERIOU." INOIF to municipals with secondary Ireatmenl requirement, enter ?II-day average of sample <br />measurements under "AVERAGE" and corer maximum 7~day average of sample mcasttremenls obtained during monitnrin6 period under <br />"h1AXIMUM". <br />6. Enter "PERMIT REQUIREMENT" for each parameter under "QUANTITY" and "QU.ALITI"' as specified in permit. <br />7. Under "NO. EX" enter number of sample measurements during monitoring penal that exceed maximum (and/or minimum or 7-day <br />average as appropriate) permit requirement for each parameter. If none, enter "0". <br />g. Emer "FREQUENCY OF. ANALYSIS" bath ns "S.AAIPLE DfFASU REMENT" (actual frequency of sampling and analysis used during <br />monitoring period) and as "PERh11T REQUIREMENT" specified in permit. (e.g., Enter "CONT." (or continuous monitoring, <br />"1/7" for one day per weeA, "I/?0" for one day per month, "1/90" (or one day per quarter, etc.) <br />9. Enter "SAMPLE TYPE" both as "SAMPLE. MEASUREMENT" (actual sample type used During monitoring period) and as <br />"PER AfIT REQUIREMENT." (e.g., Enter "GRAB" for individual sample. "2aHC" (or '_A~hour composite, "N/A" for continuous <br />monitoring, etc.) <br />116x1! 3a7H a7od) <br />10. WHERE VIOLATIONS OF PERMIT REQUIREMENTS ARE REPORTED, ATTACH .4 BRIEF EXPLANATION TO DESCRIBE <br />CAUSE AND CORRECTIVE ACTIONS TAKEN. REFERENCE EACH VIOLATION BY DATE. <br />11. If "no discharge" occurs during monitoring period, enter "NO DISCHARGE" across form in place of data entry. <br />12. Enter "NAME/TITLE OF PRINCIPAL EXECUTIVE OFFICER" with "SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />AUTHORIZED AGENT;' "TELCPHONE NUMBER" and "DAi E" at bottom of form. <br />13. A1ail signed Report to Office(s) by date(s) specified in permit. Retain copy for your records. <br />14. Afore detailed instructions for use of this DISCHARGE MONITORING REPORT (DMR) form may be obtained from Office(s) <br />specified in permit. <br />LECAL NOTICE <br />This report is required by law (3? U.S.C. 1318: 30 C.F.R. 122.22). Failure to report or failure to report truthfully can result in civil penalties not <br />to exceed $10,000 per day of violation; or in criminal penalties oat to exceed $25,000 per day of violation, or by imprisonment for not more than <br />one year, or by both. <br />3213 H <br />d Wtl15 <br />3~tl1d <br />ONOJ33 3tl3H OIOd <br />aatNa 3aaR aiod <br />213H 3~dV1S <br />:' <br /> <br />