Paperwork R:eduction Ate°I V~.;~. if: e
<br />Public reporting burdzn Err this r~~l ltaioo of infi•rmanun is eslimatul iu .,i,y ~nr ran~z of 10 ~,,uc: as an
<br />average per response for .,erne mm~ a facilities, to 110 hours as an averagz p: r r~ -,~~ ~n+:. fur .gym,: ma;or fa:'.ilines
<br />with a weighted average for ma}or anJ minor facilities of l8 hour.+ p~:r rc~lun~~~, ~.n~~ludtn~ uen., for r.;~iewing
<br />instructions, searching existing da!a sources, gathering and mainniimng I+ d:0.u nz.•dzd, and cnmplehug ad
<br />reviewing the collection of information. Send cormnents regarding thz bur}eo : •urnete ur anv other :aspect of
<br />this coltection of infortnaliun, including suggestions fur reducing this bu.deu, w Chief, Inlotatation Policy
<br />Branch, PM-223, U.S. Envrronmenld~.l Protection A.geocy, 401 M Street, SW Wa~;hingtun, DC 7(1460; anJ to the
<br />OFI-ice of Lrformation and 12egulatory Affairs, Office of Management and Bud;et. W i~hmgton, DC 20503.
<br />General Instructions
<br />1. If form has been partially completed by preprinting, disregard instructions direaed at entry of that information
<br />alrrady preprinted.
<br />2. Enter "Permittee Name.:44ai(ing ,Address (and facility name location, if di(ferenQ," "Permit Number," and
<br />'Discharge Number" where indicated (A separate form is required for each disch:ageJ
<br />3. Enter dates beginning and coding ':4/oniroring Period" covered by form where indicated.
<br />4. Enter each 'Parameter" as specified m monitoring requirements of pernut.
<br />5. Enter "Sample A-leasvrer~r~ n!" data for each parameter under "Quantity" an.l "(iualitr" m units specified in permit.
<br />"Average" is normally arithmetic atrrage (geometric average for banenal liar rncler,) of all sample measurements
<br />for each parameter obtained during ".lloniloring Period'; "Afaximurn" .u+d "li;;i riu+u" arc normally e~areme high
<br />and low measurements obtained dtring "alunitoring Period." (Not:: to ^i,inicipals with secondary treauncnt
<br />requirement Enter 30-dav average of sample measurements under " Irergr;~," tnd enter mavmum "!-,lay average
<br />of sample measurements obtained during monitoring period under ",tlax;uiu~+r "~
<br />6. Enler'Permi! RequiremenP' for each parameter under "Quantity" and "Qrm1,rV" ,LS slwcificd in ?ermit.
<br />7. Under "No Fs" enter number of sample measurments during mondoring perod `.gat c~tted mss:irr.um (atn}/or
<br />minimttm or 7-day average as appropriate) permit requirement for aach paramde: 1` conc. enter "0".
<br />8. Enter "Frequency njAn.zysis" both as ':Sample alensvrnrenr" (actual .`rerlucnc} +~` svnplin;g and a~~llysis r:..:d
<br />during monitoring penal) and as "r'enuit Requiremen!" specified in pernut (e.};. Enter "(~)nl," fie! wntinacis
<br />monitoring, "(/7" for one day per ~a•eek, "li3U" for one day per month, "/ ~0" fo~ one d.ry per quarter, c::.)
<br />9. Enter "Sample Type" both as "Stnnp(e ,LfeasuremenP' (actual sample hZ"; +sed drrv~c monitoring period) atul s
<br />"Permit Requirement," (e.g., Enter "Grab" for individual sample, "'~H"" For .'; hour composite, "A'!A" for
<br />continuotrs monitoring, e[c.)
<br />10. Where violations of perrrut regturenients are reported, attach a brief esplanaU?n to tlscribe cause and correcti,z
<br />actions lake0. and reference each violation by date.
<br />11. If'no discharge" occurs during monitoring period, enter "No Discharge" acrrss form in place of data eiary
<br />12- Enter "Name/I'ille of Principal Fxecuhve Officer" with "Signature o11'rmrrp,r~ Iir:virve OyTicer q.'.?uthnrc; d
<br />Agent," "Telephone Number," and "Date" a[ bottom of form.
<br />l3. Mail signed Report to Vice(s) by date(s) specified in permit. Retain cop? for your records
<br />14. More detailed instntdions for use of this Discharge rLloniforing Report (U'.fl•J form m.:y be obtained from Office;:)
<br />specified in permit.
<br />Legal Notice
<br />This report is required by law (33 U.S.C 1318; 40 C.F.R. 175.27). Failuro to report nr fai'are to report truthfully c:m
<br />testtlt in civil penalties not to exceed $ l0; J00 per day of violation; or in criminal :~znahios no' to excx i S25,G(Kl pet d:..
<br />of vio4tioa, or by imprisonment for not more than one year, or by both.
<br />IEPA Fotm 7J20.1 (Rev. OS-95)
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