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<br />Public repoting burden for this collection cf ~fotmation is estimated to vary from a range o" .0 horns as an
<br />aee.~ge per response for some minor fact ;i_es, to 110 hours as an Overage per -esporse for some sajor
<br />facilities, with a tieighted average for majo. and rainor facilities of 1S ;tours pe_ response, inc.[:drag imo for
<br />reviewing instructions, searching existing iaa sources, gathering aad maintainug the ~:r. rez~~~d, gad
<br />completing and reviewing the collection o'; information, including suggestion fo* reducing : is b~irden, to
<br />Chie ;Information Policy Branch, Pik-22. , 'J.S. Environmental Protection tlgency, 401 i!C tree', :.`~!.
<br />V.'asilington, BC 20460; and to the Qf`+ce o.'. formation and Regulato_; Ai'airs, C `fice of i~rsnr gP ~ _~n_ ~d
<br />Budget, Washington, I?C 20503.
<br />
<br />1. If form has teen partially completed by pi. tinting, disregard instruction directed ct entry of tl"t i ,fcrrna:=on airead;
<br />preprinted.
<br />2. Enter "Perl:Jittee iJome/l~oiling Address (a .1 facility aameAocation, if diuerent); '' P.;rni! idun•F_ ." and. "Di 4a;s~
<br />Numf:er" where indicated. (A separate form i s required for each discharge.)
<br />i,. Enter dates beginning and editing "Ivoaitoni.', Pet iod' covered by form w'ne ~ iadica.~d.
<br />•i. Enter each "Pora,ne~er" as specifed in mob crng requirements of permit.
<br />5. inter 'Sample irleasuremenr"data fcr each
<br />~orraally arithmetic average (~cometr,'c a•!c
<br />obtaned duri,tg 'irlonttori,7g Pariod'; ':~i~
<br />obtained during '4'eonitoning Pe.io a". (1\Tnt
<br />of sample measurements under Aver age, "
<br />monitoring xriod under "i/exinc~~t. "j
<br />ammeter unde-. "Q.tantiry"anu (h~ality" as : pacified i r - _ merit. `.;ve.• ae`' is
<br />;,e for br_acrial parameters) of all sample a-~asw~me~at :or ea_ , pr -mere
<br />fldtli.J" and 1V!%,7li7tlft" are nCi?;a~ly e~ _~i is hlgh a~li JC! n'J3Sll CIIwiu
<br />~o municipals vtith secondzr; treat7nerl ra _~irement: ~r Fr 30-gay ~• erag°
<br />r3 ent=: ma,cimum 7-day avc:asc of ranp'~ measu*e tee-:~ aL-~ Lei dur'ro
<br />v. Enter :°ermit R~quirenenl"for ea.c:~ panitr ~r under "Qua,ttity" and "Quotity" s s}-ci~,:d in pewit.
<br />7. Under "No Ex" enter number of samr'e me. ~!-emert during moai~criag r_:'.od tint u::cced ma;:irrr ~:1~d/c- a ri.nu_:_
<br />or 7-nay ave•age as appropriate) permit regt• :;inert for each parameter, If none, ca.c • "0 '.
<br />3. Enter "Fre;~u°ncy .fArrolysis" boll[ rs "Sa..p:s %::_asunet:;ent" (actual fregreac;• of sarpling a.nd e~alysis sec eurir.g ,
<br />monitoring period) and as "Pe,;;tit Requirel.urt" specified in permit. (e.g. 3n_er "Con'," for coatinucr: monitcria~, "1/7" i
<br />for ore day per week, "1/30" for gee day pe Won't, "1/90" for one day per quarter, ~ :.)
<br />9. Eater "Sa+~tple Type" both as "Sample ffeos resent" (zctual sample type used during n,~nitoring ~cr iod) anL as 'Perini'
<br />Regttirement," (e.g. Enter "Grab" for irk:%:dual scmpie, "141iC" for 2~~uour cenposite, 'T.'/~~'' fo; cortiaucu.;
<br />monitoring, etc.)
<br />10. ~iJhe;e violations of permit requirements ar.. r ;rwrted, attact a brief explanation to d :sc be cause ~ ~ co:tecdve actic n,
<br />to be taken, sad reference each violation by ['.ate.
<br />1 I. If "no discha,~e" occurs during monitoring r.;riod, enter `No Discharge" across form ;n place of darn entry.
<br />12. Enter "NamelTitle of Principal Ezecutiv.- CiffJCer" with "Signature of Principa! E.=eeulive Officer of Aut':orizec:'
<br />Agent, ""Telephone Number,"and "bete" at bottom of form.
<br />13. Mail signed Repott to Office(s) by date(s) s; eciGed in permit. Retain copy for your r:.co_ds.
<br />14. Mon: detailed instructions for use of this ~ ischarge Monitoring Report (DIdRJ for m may be ob~i;:ed from Cffice;s)
<br />specifed in permit.
<br />:~~~~~ 1~®~~~~
<br />This report is required by Iaw (33 U.S.C. 1318;'!0 C.F.R 125.27). Failure to report or fat trre to report tr. t fully c~ result it
<br />civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 :;cr day cf vi~latio~,
<br />or by imprisonment for not more than one yeaz, ar both.
<br />Ful'A Fort 33Y0-1 (it¢v. 03/x)
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