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<br />Public reporting burden for this collection c .°infomation is estimated to vary ,tom a range of 10 homes as an
<br />average per resronse for some minor faci~ `yes, to 110 hours as an avetage per response :"a- some major
<br />facilities, with a weighted average for majo:• and minor facilities of 1>3 hours per response, including t ~mc for
<br />reviewing instructions, seazching existi,-tg :?ata sources, ga':hering z,:c maintaining the data needed, and
<br />comp(etir_g and reviewing the collection oi' infomation, including suggestion fa• reducing `;;`s bu-de--, to
<br />I C=sic ; Inormation Policy Branch, PY-223 J.~. Environmental Protection F.ge_~cy, 4C1 ?!-_ ~t-eet, &.bU.
<br />UVashington, CC 204.60; and to the Of_ICe cf'Infomation a_*td Zegulsto_ry F.ffairs, Cffice cf ~'irnagca.ent and
<br />Budget, dVashington, BC 20503.
<br />
<br />1. ?f form has been partially completed by pr ~rnting, disregard instractioa c:irzcted at entry of t:~at irfo.-~na'ion slready
<br />preprinted.
<br />2. Enter "Permittee Name/iv.'oiling f:dd;ess (r ; `acility name~~oca+ion, if iiff~ert)," '' P_rrtit Nur,•1-e.•," anc "Cceha;ge
<br />Number' where indicated. (A separate fo,z± is ; equired for each discharge.)
<br />3. Enter dates beginning and editing "IJ.O:'ILOn ~ Pe;ind" covered by Corm where ~rdica:ed.
<br />4. Enter.each "Parameter" as specified in men : ing .~quirements of pemrit.
<br />5. Enter Sartple ivleasurertent"data for eecb rmctc- urde~ "Qvantiry" and Qra/iC+" ~ c ~_cined in c.~ni:. "`ve, ages is
<br />formally arithmetic wemge (geomcYc ave gc for'~:.ctcrial parameters) o"rl' sas,~~s ~r:rsureme_.ts !'or ea.:•, pr Mme u-
<br />cbained during ";/,o:,itoring Pe•ird'; "ill...%;; u;;r" and.rYli,towr.," arc ccr,^lly e, sr:.c high a-d '~c.' m asurmc:,:;
<br />obtaucd during "Monitoring Period". ~D!et to mua::Jpals r:itb sccondanj Saatmerl req.:irement: _'r._cr 30 gay iverage
<br />of sa_~rple measuremen's under "Av:,~aoe," rd cry • maximum 7-day ave aga of sar tp'a measetc.~c, t, ob:a ^cd c~=rg
<br />monitoring period under "N<asimum.")
<br />6. Enter 'Per;,tit Requirement" Cor each parao= er under "Quo;~tity"and "Quclity" as sp~cif ed in pcrc.it
<br />7. Under "No Ex" enter number of sample me :. *erer t during monitoring l:eriod that .;zecad maxima ~ ;rrd.'c- m aimum
<br />or 7-day average as appropriate) permit regi cement for each parzmeter. If vane, entc- "G ".
<br />8. Enter "Frequency ojAaolysis" bo@r as "Sa. r/e :/.eascrement" (actual frequency of sampling a;.d ~rslysis '_sei during
<br />monitoring period) and as "Pzrn%~ Require,.. ant" specified in permit. (e.g. Ester "Co:: ~, "for continuocs :non't~rin„ "L7"
<br />for one day per wee!c, "1/30" for one day pe. month, "I/90" for one day per quarter, etc.)
<br />9. Enter "Sample Type"both as "Se;aple Ir1ea.• reme;~l'' (a:,tual sample type used during moni[oring prsd) arc as 'Pe:,ni~
<br />Requiremen{" (e.g. Eater "Grab" for ir~iividual sample, "24HC" for 24-hour composite, ";'.'/~" fo: continuous
<br />monitoring, etc.)
<br />10. Whena violations of permit requirements ar. reported, attach a brief explanation to describe cause a-u: con-ective actions
<br />to be ta6en, and reference each violation by date.
<br />11. If "na discharge" occurs during monitoring - Jriod, enter "No Bischazge" across form ~ p~aae of data carry.
<br />12. Enter "NamPlIF[le of Principal Executiv:: Office," with "Signature of Principal Executive Officer of kuthorized
<br />Agent, ""Telephone Number,"and 'Date"at':ottom of form.
<br />13. Mail signed Report to Office(s) by date(s) s:iacified in permit. Retain copy for your r: cords.
<br />14~. Mora detailed instructions for use of this ilischage Monitoring Report (DIvII2J form may be obL-:rcd frc,n C.nce(s)
<br />specified in permit.
<br />This report is required by law (33 U.S.C. 1318; 4C C.F.R 125.2'!). Failure to report or fa`.are to report trc*tlrfully can result ~~
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 par day of violation,
<br />or by imprisonment for not more than one year, cr both.
<br />L~PA For® 3320-fl (I2ev. 03/40
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