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Paperwork Reduction Act Notice
<br />Public reporting burden for this ~.rrllection of information is estimated to very from a range of 10 hours as an
<br />average per response for some minor facilities, to 110 hours as an average per response for some major facilities,
<br />with a weighted average for major and ruioor facilities of 16 hours per response, including time for reviewing
<br />instructions, searching existing data sourc.s, gathering and maintaining the data needed, and completing and
<br />reviewing [he collection of information. Scod comments regarding [he bwden estimate or any other aspect of
<br />this collection of information, includint; suggestions for reducing this burden, to Chief, Information Policy
<br />I Branch, PM ?23. U.5 Environmental Pro[a~tion Agency, 401 N. Street, SW Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affairs, Office of Management and Budge[, Washington, DC 20503.
<br />General Instructions
<br />1. If form has treeo partially eonpicted L preprinting, .:::regard instruction diruted at entry of that information
<br />already preprinted.
<br />2. Sntef 'Permi(1re >:ame:11ni1,::g 4d~bacr fn-,d rarihty nameAocation, I different)," "Permit Number," and
<br />"Cischm•;:;e ,\'umbcr" rr~here rr.rlicaica. (.1 s_parata'ann is required Cor eac'; discharge.)
<br />3. Emcr dates beginning and endutg "A/o nfori,;,~ P •-rod" :avered by Corm ehcrc indicated.
<br />4. Enter each "PUrmrreru " as specili•:d to n'.oni[ortng -.~.qc:. ~_ments of permit
<br />5 F,ntcr "Sornpk• "..',-a.,-;~,•.'r~•~ t" ds!~ fn: c; ;h parameter r..,der "Quunrin'" ar d "Quoliry" in units specscd in permit.
<br />"J~,-ernge" is aern~aily anthmc .c a~~.cr,tg_ (;;c~.:~~rare a•.~ .age for i,actetial oanmeters) of all sample measurements
<br />for each paramcrer nbl.:inca during "~ Ln:u;:-„~¢ P. ri„n , ",t frvir.:u:;," anc "{!rnimum" ar normally extreme high
<br />,.nd low mcasurcrncnts obtni•i•:d aurn "i!s;.rr.•i+g , -r;r.a." ;NMc ;~ munuipals wnh secondary treatment
<br />!ryairemerd. Enter lU-dav avu~agc u..>.'mple t.ra;;,r.~nenU und~:r ":1va~, ~er." and enter maximum 7-day average
<br />of snmplc mcasur:n rats nbt.iin ~ do: i:,p, ~nonit~ gyn.: pcr:od under ".41az,mum.
<br />6. Enter "Permit Requ,~~nrani" fci tint[ pr:,tm.~r: t,n•..^ "; m.ntrty" and "Quc':;r" as specSed~in permit
<br />7. Under ':vu Er" enter numMr ~i :a:npie me, t• :' °nts during mca'r,o,+,e ceriod that exceed maximum (andlor
<br />minimum or '-dac acrraGe a~ ~porap ~~tet pen~~:~t' ~quirement for each par::meter. If none, enter "0".
<br />8. Entet "Frge'~r. ) lna;sis' o„'h ~r~ "A,::.,,~1., '.:m~wx,'nP' (ac,ual fr~gcency of sampling and analysis used
<br />dnnr:g mona~r.+~ (`L^"~!1 .-r? ?_ ";'= ~:,: h'rq~.o••anent" sp"cil:e9 in pcr..it (e. g., Enter "font," torcontinuous
<br />nunrtotinn. ": ~%' f,r ,nr a::y i:., ~.:e:.. ', 'J" or one day per mouth, "/ n%" roe one day per quarter, etcJ
<br />9. Enter "Snmp(e %~ j,.-' hoth as 'v-:~ral~ 1'ensurr,":::," ;;:.iuat sample 4P~ used during monitoring period) and as
<br />"Pt•rmi, .4efuiremen(," (c.g , ''titer "tirnh" fnr indivrrlual sample, "2di%("' for 23-hour composite, "N.!4" for
<br />continuous monitoring, etc.)
<br />lU. Where violations of pc:mit r~yan,:.tie^.:~ a.e r.:Fo;red, attach a brief exn:.mation to describe cause and corrective
<br />actions Taken, end reference eac': • ;ola'ion by date.
<br />11. If "no discharge" c;cacs during menitu ang »enn-t, enter ",vo Dischnrge" a:ross form in place of data entry.
<br />1?. Enter '.~'arne/I'ille nfPrincipa+ Fzecurn'e O,!j:~'.i~ with "Signature ojPnncipal Fseculive OJTceraJAulhorized
<br />Agen(," 'Telephone JVanrhrr," and "Dar" et bottom of form.
<br />13. Mail signed Report to OFfice(s~ by da.tc:,l spc.:.rf cd in permit. Retain copy for your records.
<br />l4. More detailed instnuctions far esc .:' ~h - U;ch,,:rqc ,Non,toring Repnrr p~4 Ct) form may be obtained from Office(s)
<br />specified in p°tntit.
<br />? e~~tl Notice
<br />'Phis report is required by law (33 :J :i. C. ItlB; J~ C.'- +f. [25.27). Fa'fure to report or failure to report truthfully can
<br />result in civil penalties got to exceed 5'0,000 vcr ury .:; ,at .m; or in criminal ; anaities not to exceed 525,000 per day
<br />of violation. or by imp.isonmeni for ny -tine. [her, ~~m 'year, or 6y both. .
<br />EPA Form 332il-1 ['Rev. U9-Y51
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