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Paperwork Reduction Act Notice
<br />Public reporting burden for this wllectir,o of information is estimated to vary from a range of 10 hours as an
<br />average per response for some minor fact hies, to 110 hours as m average pe: respouse for some major facilities,
<br />with a weighted average for major and minor facilities of IB hours per response, including time for reviewing
<br />instructions, searching existing data sou-czs, gathering and maintaining thr, data needed, and completing and
<br />reviewing the collection of informahoo. So„d cornmenrs regarding the burden estimate or any other aspect of
<br />this collection of inforuation, in. tiding su~R~e.rions for reducing this burden, to Chief, Information Policy
<br />Breach, PM-223, Ii.S. F.nvirunmrntal Protrc4on Agency, 401 M Street, 5'.V Washington, DC 20460; and to the
<br />Office of Information and Regulatory Affuirs, Office of Management and Budget, Washington, DC 20503.
<br />General Instructions
<br />1. If form has be.n pe-t;~lly cumpt_twi h; p-epri;tin„ d~eregaid ios[nictions direzted at entry of that information
<br />a:ready proprintu!. ,
<br />2. Pour 'Trrnritrer Ko•ne~brni'rno 4d,lr:~ce fa:~~ f~aLt~• name.9oca;iar. it dilTerenq," "Permit Numher," and
<br />"Prschnr;~e ,'15ur;~rer' •.•~here indica:~:d iA se n;:, aye fa-m 's requirai (or eact discharge )
<br />3. Eater dates bzgi:,aG~, and cr•di ig ' ~.; : r.,a. ;~ , ~ ••ur i" c_'.ered by form an se indicated.
<br />4. Enter each "Paramzlr•~" as speaGcd in s:~r.•:nm•c rc ;uucments of perrut.
<br />5. i:ntcr "F<:;nplr S:~r.~:,.;r•r:•°r:" ~ r e:rL ~~a;.a:ne':r +erd.•r "Ilunrrtin" st ; "Quality" in units specified in permit.
<br />":I ~eraF~" is ncr:rc i, an;t,~,:•~'.c~ ,..,;e (~~.~~:,_' ~: a• ;n,e for bacier;al ,arametcrs) of all sample measurements
<br />tnr e'~.it parar.*alzr o~n:.incd d~ nn,^ •'+!,re.. ,_ r'.:~r.rd'; 'dlnxin:u~:" .,n% "Slmi~mm" arc normally extreme high
<br />and Ie:r u~sur;icr:a eh:..~r.rd ~. ~,i.e.'n'n,;rO:U:L ,'.ord." (Nnc '• municipals with secondary treatment
<br />iequircm.:a Ertr :"»ia: P:`!it'. J! si n,r :r-.. •: ;n, nt, cm1, r ",rv"•-:. c: ." and en~er maximum 7-day average
<br />of sample nl'a~wr: ma:~ •abl:, r„ .' d'a:'i~ a .,:.~:, ,. mg perwd under ".1 •alin:r: n."
<br />6. Enter "Prrmi; K. ~,nr,•nrent" r.,• ,:: ~: r ran ..,rr cn?:-:. •; ,r.nnrR~' ^nd "(.u.:.:y" as specrfied in permit.
<br />?. ')rdcr "ve f-' ta! r r.tnnr ,; ~, -~.n~+!~ ; _,..u;:,,r:,a during , oaho ~,.. penod that exceed maximum (and/or
<br />mir.ltrlel ~. lir -~S.,;a,'^rlFC a•appropil,Ie?!~i:-~r ro~::Rrm_n[for earh parameter. If none, emer"0°
<br />R. Enter ".`~""r.•rrr•.:: „r '•ra;.•r., h •m } "• • ~. a : •nenr" lncrn:J f•. gne:~c} of sampling and analysis used
<br />during. monrtorr,., ; •.:. ; :,•.. 'r : ;'^rr...r:;t•r nr' ;pcci5ed in pan ;r (._.g., Entcr "Coot," for continuous
<br />'ro~rlonrn, ° i" i:. ..,:. d• ; c•:r art: '"; „'' .n: or., da} per month. ", ,. rnr one day per quarter, etc.)
<br />9. F,nler ".ir.nrp!: 1;.;:. ' bo±h ~~ "•,.r„•;;/e ' :r. ,,,•-. , :., '.:..mat s::^.~ple ;gip, iscd during monitoring period) and as
<br />"Permit Reywrer.,crn " (c ~., 13~.:~_r ' "irai,~ :.~ i;~.~liv~daal sample, ".4r:~•" tun 24-hour composite, "h'•'A" for
<br />continuous monitoring, etc.)
<br />10. Where v~oiations of pemut requ'r:re't. ;:r rroonzd, .'r1ch a bnef exp.: nation to describe cause and corrective
<br />actions takcu, and reference eaci:::aa:ion ho irl..
<br />11. It "no discharge" occurs dung morrito: irg pen rt .enter ":Vo Disc<:arge" across form in place of data entry.
<br />12. Enter "h'arne/fi!!e of Principal Ere.v.nv Vr:.. •~" with `.C'ignab:re o(Pr.aripa! Executive OJTcer of Authorized
<br />~Agerrt," "Telephone ,Y:rmber," a'+d "Dn;e" ~t F,o! ant of form.
<br />13. Mail signed Repon [v O+fiice(s; 'ay dz;r, ;• spc:i; : -i .r. permit Retain eeNy car your records.
<br />14. More d~[.tiled ins:n~ctiors'rr t~sz c; 0' :. " .:.:,~•• ,Uonrroring Rr;~ort ,?".. Rl form may be obtained from Office(s)
<br />specified in perms.
<br />~: s~:t~ ~OtICC
<br />This report is n;quir.'.I br i,rw (?3 U.;i.i' L ~! , !! r i~.R. L°5.27). F.ulur•. t•~ , port or (attune to repoR truthfully can
<br />result in civil ,r, nalhe:-. ant 'r ez..e, J .; IC :`:1 n •- 'ati• _!ar~no: or in criminal L, aalties not to exceed x25,000 per day
<br />of violatioc, cr by imprisonmeoi f; r .,ot mr; c tr.~~ r.~, ::.•ar, ; . by both.
<br />EPA Farm 3320-1 trte~. OH ^ +?
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