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Paperwork llteduction Act Notice
<br />Public reporting burden for this collection of information is estimated [o vary from a range of 10 hours as an
<br />average per response for some minor facilities, to l 10 hours as an average per response for some major facilities,
<br />with a weighted average for major and minor facilities of IS hours per response, including time for reviewing
<br />instructions, searching existing data sources, gathering and maintaining the data Deeded, and completing and
<br />reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of ~
<br />this collection of information, including suggestions for reducing this burden, [o Chief, Inforn-atioD Policy ,
<br />Breach, PM-223, U.S. EnvtronmeDtal Protection Agency, 401 M Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of Management cad Budget, Washington, DC 20503. ;
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<br />General Instructions
<br />1. If form has been partially wmpleted by preprinting, disregard instructions directed at entry of that informatioD
<br />already preprinted.
<br />2. Enter "Permit(ee Name?~failing Address (and facility name/location, if dif3erent)," "Fermi! Number," and
<br />"Discharge ,Vurnher" where indicated. (A separate form is required for each discharge.)
<br />3. Enter dates beginning and ending 'itlonitoring Period"covered by fomt where indicated.
<br />4. Enter ench "Pararne(er" as specified in momlonng requirements of permit.
<br />5. Enter ",Sample Aleasurement" data for each paamcler under "Quantity" and "Quality" in mots sp;cdied in permit
<br />"Average" is normalh arithmetic average (geometric average for bacterial parameters) of all sample measurements
<br />for eac(r parameter obtained during ",ifnnrmru;g Pe•noC'; ':4laxrmmn" and ",14immum" arc normal} c~Krem~_ high
<br />and low measurements obla9ned during ".tlaritonng Period" (Note to municipals w~(h secondary treri'nient
<br />requirement Enter L)-dap average of smnplc mcastrrcmenls under ".lverage," and enter maaimcm 7day average
<br />of sample measurements obtained during monitoring period !older ".Llorimwn.'J
<br />6. Enter "Pervntl Requirement" for each parameter under "Quantity" and "Quality" as specified in permit.
<br />7. Under ",'v'o Ex" enter number of sample measurments during monitoring period that c~ceed maximum (and/or
<br />minimum or 7-day average as appropriate) permit requirement for each parameter ff none, enter "0".
<br />8. Enter "Frequenc}~ oj.4na(vsis" both as ".Sample .4leosurment" (actual frequency of sampling and anal}sis used
<br />during monitoring period) and as "Permit Renuireuren(" specified in permit. (e.g., En[cr "Cant," for continuous
<br />monitoring, "1/7" for one day per week, "1'30"for one day per month, "1/Sr0" for one day per quarter, etc.)
<br />9. Enter "Sample Type" bosh as ".Sample Afcasuremenr" (actual sample typo used during monitoring period) r;rtd as
<br />"Permit Requirement," (e.g., Enter "Grab" for inditidual sample, "2dffC" far 24-hour composite, "iJ/A" for
<br />continuous monitoring, etc.)
<br />10. Where violations of permit requirements are reported, attach a brief e~cplanation [o describe cause and corrective
<br />actions Yaken, and reference each violation by date.
<br />11. It "no discharge" occurs during monitoring pcriDd, enter "No Discharge" across form (n place of data entry.
<br />12. Enter "Name//'itle ojPrincipal Executive Officer" w~(h "Signature ojPrincipal Executive Officer ofAuthnrized
<br />Agent," 'Telephone Number," and "Date" al bottom of form.
<br />13. Mail signed Report to Office(s) by date(s) specified in perntit. Retain copy for yotu records.
<br />l4. More detailed instructions for use of this Discharge Afonitoring Report (DMR) form may be obtained from OBice(s)
<br />specified in permit.
<br />Legal Notice
<br />'Ibis 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 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 on.: year, or by both.
<br />,EPA Form 3520-1 (Rev. 08-95)
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