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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 ac
<br />average per response for some minor facilities, to 110 hours as an average per response for some major facilities,
<br />with a weighted average for major and mioor facilities of 18 hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
<br />reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of
<br />this collation of information, including suggestions for reducing [his burden, to Chief, Information Policy
<br />Branch, PM-223, U.S. 6ovironmental Protection Agency, 401 M Street, SW Washington, DC 204b0; and to the
<br />Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />already Preprinted.
<br />2. Eater 'Perini(tee Name/14fai(ing Addreu (and facility namellocalion, if different)," "Permit Number." and
<br />"Discharge Number" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and ending '~tfonitoring Period" covered by form where indicated.
<br />4. Enter each "Pararnerrr" as specified in monitoring requirements of permit.
<br />5. Enter "Sampfc .4lrasurement" data far each pa.'amctcr under "Quantity" end "Quatinrv" in units specified in permit.
<br />"Average" is normally arithmetic average (geometric average for bacterial parameters) of all sample measurements
<br />(or each parantder obtained during ",llnnitoricg Period'; ".tlaxmrorn" ar,d ",tlinirnurn" arc normally extreme high
<br />and low measurements obtained during ",tfoniturmg Period." (iJote to murticip:.ls Hith secondary treatment
<br />requiremenC Enb_r 30-day accrage of sarnplc measurements under ".average," and enter maximum 7~ay a•;emge
<br />of sample measurements obtained during monitoring period under "dlaxunum.
<br />6. Enter "Permit Regvire•ment" for each paramdcr under "Quantity" and "Quality" as specified in pcruril.
<br />7. Under "No F:r" enter number of sample measurements during monitoring period tact exceed maximum (and/or
<br />minimum or 7-day average as appropriate) pcrrtiil requircmcn[ for each pa~ameter. tf none, enter "0".
<br />8. Enter "Frequency oJ,-lnalysis" both as "Sarnp/e .t/ea.curment" (actual Irequcncy of samp:ing and analysis used
<br />during monitoring period) and as "Penrtit Reruirenrenl" specified in permit. (e. g., Enter "font," for continuous
<br />monitoring, "1,7" for one day per Week, "1/30" for one day per month. "1/90" for one day per quarter, etc.)
<br />9. Enter ".Sample Type" both as "Sample ,lfeasurernena" (actual sample type used during monitoring period) and as
<br />"Permit Requirement," (c.g., Enter "Grab" for individual sample, "ZdNC' fo: 2~-hour composite, "~!/f " for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements arc reported, attach a brief explanation to describe cause and cortxtive
<br />actions taken, and reference each ~~o{ation by date.
<br />11. If "no discharge" occurs during monitoring period, enter "N'o Discharge" across form in place of data entry.
<br />12. Enter "Name/I'itle of Principal Executive Officer" with "Signature ojPrincipat Executive Officer oJ.9ulhorized
<br />Agen(," "Telephone Number," and "Date" a[ bottom of form.
<br />13. Mail signed Report to OBice(s) by date(s) specified in permit. Retain copy for your records.
<br />14. More detailed inswctions for use of this Discharge A•fonitoring Report (DAdR) forth may be obtained from Officers)
<br />specified in permit.
<br />Leal 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
<br />result in civil penalties not to exceed 510,01)0 per day of violation; or in criminal penalties not to exceed $25,000 per day
<br />of violatioo, br by imprisonment for not more than one year, or by both.
<br />EPA Fotw 3320-1 (Rev. OS-95)
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