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Paperwork lr'.eduction Act Notice
<br />Public reporting burden for this collection of information is estimated to vary from a range of 10 hours as au
<br />~ average per response for some minor facilities, to ] 10 hours as en average per response for some major facilities,
<br />with a weighted average for major and minor facilities of 18 hours per response, including trine for review in;
<br />instructions, searching existing data sources, gathering and maintaining lha data needed, and completing and
<br />reviewing the copection of information. Send comments regarding the burden estimate or any other aspect of
<br />i this collection of information, including suggestions for reducing this burden, [o Chief, Infonnztion Policy
<br />Branch, PM-223, U.S. Environmental Protection .4gemcy, 401 M Street, SW Washington, DC 20460; 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. Enter "Permittee A'amei,~failing Address (and facility namellocalion, if diffcrcnQ," "Permit Number," and
<br />"Discharge Number" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and ending 'S~loniroring Period" covered by form where indicated.
<br />4. Enter each "Parameter" as specified in monitocng requirements of permit.
<br />5. Enter ".Sarnple.4/easuremenP' tiara far each panuneler under "Quantity" and "Quali!}" in units specified in permit.
<br />"A ~~~erage" is norntall~ arithmetic average (gcoroctric at~cragc for bacterial parameters) of all sample mcasr~rcmrnts
<br />Cor each parameter obtained during "'frm6rrir~,q Perron!"; "Alaxirnunr" and ":Llinimunr" arc nonnaliy extreme high
<br />and low measuremens obtained during " 1lositonng Period." (Note to me~icipals with secondary treatment
<br />requirement: Emer 3Utla} average of sample measurements under ".1 verage," and enter maximum 7-day average
<br />oCsample measurements obtained during monitoring period under "A/aximnm.')
<br />6. Enter "Permit Requirement" for each pararnctcr under "Quontiry" and "Quality" to specified in permit.
<br />7. Under ".Vn Fx" enter number of sample measurments during monitoring period Ilrat exceed maximum (and/or
<br />minimum or 7-day average as appropriate) pcmrit requirement for each parameter. If none, enter "0".
<br />8. Enter "Frequency oj,9nalvsis" both as "Snmple .b/eacurment" (actual frequency of sampling and analysis used
<br />dunng monitoring period) and zs "Permit RenuireutenP' specified in permit. (e.g., Enter "font," for continuous
<br />monitoring, "1/7" Cor one day per week, "/:30" for one day per month, "!/40" for one day per quarter, etc.)
<br />9. Enter ':Sample Ttpe" both as "Sample ,lleasrtrernenP' (actual sample type used during monitoring period) and as
<br />"Permit Requirement," (e.g., Enter "C;rab" for indi~idtral sample, "2•J//C' for 24-hour composite, "iJ/A" for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements are reported, attach a brief explanation to describe cause and corective
<br />actions taken, and reference each violation by date.
<br />11. If "no discharge" occurs during monitoring period, enter "No Discharge" across Corm in place of data entry.
<br />12. Enter "7Jame/I'i(le oJPrincipa! Executive O~cer" with "Signature ojPrincipal Executive Officer ojAuthorized
<br />Agent,"' "Telephone Number," and "Date" at bottom of form.
<br />13. Mail signed Report to Office(s) by date(s) sped=red in perntit. Retain rnpy for your records.
<br />14. More detailed instructions for use of this Discharge Monitoring Report (DMRJ form may be obtained from OBice(s)
<br />specified in permit.
<br />Legal Notice
<br />'ILis 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 ~penslties oat to exceed S 10,000 per day of violation; or in criminal penalties not to exceed 525,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />EPA Form 3120-1 (Rev. 08-95)
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