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Paperworl~ ~educ~ou~: Act ]~iotice~ Public reporting burden for this collection of information is csitmated tr, ~ :~ .. ..~ s ar: average per response for some minor facilities, to 110 hours as ao averag: , .. . ~..~ 'n: .onr_ rca ~r fx ilities, with a weighted average for major and minor facilities of tg hours per r p~ :: n_i :drag arr. `!r rr iia-;ng, mstmctions, searching existmg data sources, gathering m~ nvainteining t .:.:... ne..~.41, any .,omplrtiag and reviewing the collection of information. Send commer.t~ r s~.rding [he oudrn ".tim+.e or a;zy other a_~t7ect of this collection of information, including suggestions fat r..Gu~mg this bu.irdeu, to ladcf, Information Policy Branch, PM-223, U.S-Environmental Protection Agency, ~iG. M Street,.S~lt W:islvngtua, DC 20460; ahd to the Office of Information and Regulatory Affairs, Office of M anagcment and Budget, tNashmglon, DC 20503 General Instruction 1. If form has been partially completed by preprinting, disregard instructons d?rec[e.l et entry of that information already preprinted. 2. Enter 'Permiftee Name/Mailing Address (and facility ttaime/logtion, if different)," "Permit Number," and "Discharge Number" where indipted. (A separate form is required for each discharge.) 3. Enter dates beginning and ending 'Monitoring Period" covered by tome where indicated. 4. Enter each "Pnrameter" as specified in monitoring requirements of pemrii 5. Enter "Sample Measurement" data Cor each parameter under "Quantiq~" yid ' Qualih" in units specified in permit "Average" is normally arithmetic average (geometric average for baderi;J pat wneter;) of all sample measurements for each parameter obtained during "Monitoring Period'; "htazimunt" anti "l. f:nintutri" are normally e;Veme high and low measurements obtained during "Monitoring Period." (Note to municip tls Hith secondary treatment requirement: Enter 30-day average of sample measurements under "Average,' and enter maximwn 7-Jay average of sample measurements obtained during monitoring period under "Alaximum. "~ 6. Enter "Permit Requirement" for each parameter under "Quantity" and "Qrrnltl}~" as sp.cified in permit. 7. Under "No Ex" enter number of sample meastrtments during monitoring period that exceed maximum (and/or minimum or 7-0ay average as appropriate) permit requiremedl for each parameter. Ir none, enter "0". 8. Enter "Frequency ojAnatysis" both as "Sample Hfeasvrment" (actual frequenry o' sampling and a~talysis used during monitoring period) and as "Pernrir Requirement" specified in penn,t. (e.g.. Enter "Cont." Tc: continuotu monitoring, "1/7" for one day per week, "!/30" for one day per month, "190" for one ~iay per quaver, et :.} 9. Enter "Sample Tvpe" both as "Sample Measurement" (actual sample type usee. dunng monitoring period) and .u "Permit Requirement," (e.g., Enter "Grab" for individual sample, "23.HC' for 2a-hour composite. "A`/,t" Cor continuous monitoring, etc.) 10. Where violations of permit requirements are reported, attach a brief explanation to describe cause ar d cor-,ecL•~e actions taken, and reference each violation by date. 11. If "no discharge" occurs during monitoring period, enter "No Discharge" across Corm n place of data entry'. 12. Enter "Name/1'ide ojPrincipal Executive Officer" with "Signature ojPoincipai Eracutive Officer ol'Autha•ized Agent," "Telephone Number," and "Date" at bottom of form. 13. Mail signed Report to llgce(s) by date(s) specified in pemtit. Retain rnpy' for yettr records. 14. More detailed instructions for use of this Discharge Afonitorinq Report (Ll4.fi2) form may be obtained lion: Dffice(s} specified in permit. Legal Notice This report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure tc r~porl. or Friure to report truthfully can result in civil penalties not to exceed $10,000 per day of violation; or in criminal peralties not to exceed 525,000 net dad of violation, orby imprisonment for not more than one year, or by both. EPA Forst 3320-1 (Rev. OS-95)