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<br />Puul:c repoaing bt."deu for this collection of in,':~r~ ,anon i, _s;imatzd to +ar> tro-:.~ ranee of IU aou-s as an
<br />average per respons: For sumr minor facilit;es, [ol IC 'aours as an overage per response nr some major fncilir.es,
<br />with a weighted average for major and minor facilities of IR hours per response, inc'ct,ing time iot revirving
<br />im'ructions, searchiue existing data sources, gatherine and maintaining the data needed, end completing and
<br />reviewing tte collection of information. Send comments regarding the burden estimat: or any other aspect of
<br />this collection of information, including suggestions for reducing [his burden, to Chief, Informatior Policy
<br />Branch, PM-223, U.S. Environmental Protection Aeency, 401 'v1 Street, S\1', ~Vashiagum, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, O(licc of Management and liudgct, Washingmn, DC 20$03.
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<br />1. If :orm has been partially completed by preprinting, disregard instructions directed at entry of that information
<br />alr_ady preprinted.
<br />2. Enter. 'Terrnitee Nume/,14ailing .Address (and facility name/location, if differe,tU," "Pernrir A'umber." and
<br />"Drschorge Ahunber" vahere indicated. (A seperate form is required for each discharge.)
<br />3. Pater dates beginning and ending "Moniloring Period" coverzd by form where indicated.
<br />4. Enter each "Parameter" as specified in monitoring requirements of permit.
<br />$. Enter "Sample A4easuremeru" data for each parameter under "Quarttuy" and "Quality" in units specified in pemut.
<br />"= verage" is normally arithmetic average (geomz[ric average for bacterial parameters) of all sample measure-
<br />ments for each parameter obtained during "~19onitoring Period'; "Maximmn" and "Minimum" are normally ex-
<br />tr me high and low measurements obtained during "Monitoring Period. " (fNete to mu icipcls with secondary
<br />a:ct-ter.: rec!uirement; Enter 30-day average of sample measurements under "Average," and enter mavmum
<br />7-nay average of sample measurements obtained during monitoring period under "Ivfaxirnurn. ")
<br />6. Enter "Permit Requirement" for each parameter under "Quanli!v"and "Qualiq~" as specified in permit.
<br />7. Under "No E'.r" enter number of sample measuremems durine monitorine period that exceed maximum (and/or
<br />minimum or 7-day average as appropriate) permit requiremem for each parameer. If none, enter "0. "
<br />R. Etter "Freyuenev ojAnalvsis" both as "SampleMeasuretnant" (actual frequency of sampling and analysis used
<br />during monitoring period) and as "Permit Requirement" specified in permit. (e.g., Enter "Copt, "for continuous
<br />monitoring, "//7" (or one day per week, "!/30" for one day per month, "1/90" for one day per yumter, etc)
<br />9. Enter "Sample Type" both as "Sarrtple.f-leasurentenr"(actual sample qpe used during monitoring period) and as
<br />"Perm! Requirement. " (e.~., Enter "Grub" for individual sample, "24HC" for 24-hour composite, "N/: i "for con-
<br />tinuous monitoring, ectJ
<br />10. ~\'hc-e violations of pzrmii requirements are reported, attach a brief explanation to describe cauee and corrective
<br />ar[iuns taken, and reference each violation by date.
<br />I l . If "nn discharge" occurs during monitoring period, enter ",No Discharge" across form in place of data ehn y.
<br />12. Prter ",\'ame/17deofPrincipalE.recutiveOjficer"with "SignatureojPrincipalEsecutireOjfireraj.luthoricerl
<br />A~~ent, " "Tetepl~one.Nun+her, "and "Duce" at bottom of form.
<br />13. Bail signed Report to Office(s) by date(s) specified on permit. Retain copy for your records.
<br />14. Ji arc de.ailed instructions f or use of this Dischmrge hfonitoring keport (D.bfR) form ma} be obtained from Uf-
<br />Fice(s) specified in permit.
<br />.J\.Jw.. 1\ ~~r.l.....
<br />Phis r, p; .-: is -cyui:ed by lao (33 U.S.C. 1318; AO Q.F.R. 12$.2'). Paihtrc to repot cr lailure to report utnhfully can
<br />rc~ul~..., -~•. t peualtizs nut to axcecd $"A,000 per day of violaiiun; or in criminal pznaltics not to exceed 52$,000 per day
<br />of vit •r.~ i9n er by imprisonment for nui more than one y~:tr, or by both.
<br />_:"'F, :-c r. 3321-: (Ffev. S-pC)
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