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~` Paperwork Reduction Act Notice
<br />Puluic rolan.inE~ hw glen fart lhi•. r:a ii~~'ilnn nl InICfIILII I~~^ iti dcllma~~"t: ;.~ v»n~ i.:,m 9 ran pr n• ;r1 6„u.•S as a:,
<br />' average per response for some minor facilities, [n 110 hours as an average per resnnnse for some major faciG[ies,
<br />wrth a weighted average for major and Honor tacilrttes of 18 hours per ruponse, includine time for reviewing ~,
<br />instructions, searching existing data sources, gathering and maintaining the riatn nerrirr_I, z.d completing and ~
<br />reviewing the collection of m(ormalinn. Send comments regarding the burdrn rerimare ~• ~~y t.rV,r. BSrrLr of
<br />rhic collrctioe of information, inch!ding suggestions for reducing this burdrn, to Chief, InforuanGu ?olio
<br />Branch, PM-223, U.S. Environmental Protection Agency, 401 M Street, SW Washtgtou, DC 2v460; and to the
<br />Office of Informa[iom and Regulatory Affairs, Office of Management and Budget, Washington. D(' 20503. I
<br />General Instructions
<br />1 If form has beee panielly completed by preprinting, disregard instructions directed a. cn;ry of lha: information
<br />already preprinted.
<br />2. Enter 'Perrniuce Nnmc;blailing Address (and facilih~ nanrellocation, if dilTercntl " "Penmr ~~'umher." and
<br />"Drcchnrce Yumber" where indicated. (A separate form is regwred (or each discharge.)
<br />3. Enter dates beginning and ending ",tlnnitnnng Period" covered by form Hherc indicated.
<br />4. Enter each "Puromrlrr" as specified in ntoniloring requirements of permit
<br />S. Enter ",S~mplc .i1cu.,urro+ent" data fur wch parameter under "Qunnrity" and "(%uulin'' in units specified in peruu.
<br />".fi~rrn,ec" is nomtallj anthmetic ascmge (geometric average !or bactcnaJ pa.~rncirrs) of all sample measuremer4s
<br />for each parameter Gbt:uncd dwing ".I hrnilunr+,q P:o~iud"; ".1larimmn" and "; linmruu+" arc normally extreme high
<br />and low measurements obtained during "11rnun: ~or,>; I'cnud." (Note to mt~nic~n2ls r~rih secondan~ trca~nent
<br />requirenu of i:: uii~ 1C-ua~ a: u.ig, of s.uul~lr r• ~ _.u anc;•t_ under ":ir er,:,~ ~." ~: enter u~.~ximum ?-u~:~ a~~rage
<br />of sample measurcmcnls obtained dwing nioniim i,ig period under "A1ar+muu,. "J
<br />6. F.nler "Prom! Remnrvmrnr" fm! Cash paramcirr ~,~„i,-r "~Jr.nnti ;%' 2nd "Q~r~l~h-" as specif~cd !^ :;~rmrt.
<br />7. Ueda '?:;. ~" . ;cr ..am.bc. cf :•.ptc: m:.. ..,...1~ d•... °.~ mar. on^.g period that _..-sec , , , (and/or
<br />miuia~wnur ~-,;.i~a~c~dg~,r:app~r,pal.,i~ii'•=~"1y'~q"~~r:i~~~,.fG,"cirpar.,meter. If none.cn,c;r0`u
<br />u. uuo rrc'yurmV tj .v r.ui,.,.5' uGili u~ ':vuuriu :~.ruei~r mcni' (ti~i -'; 'u Cy ueiiCi G, ,.,,upu u~ ,_iiQ .,i.aij SiS used
<br />during monilonug pcnod) and as "Permit Jfcgwrrurenr' specified in pcnnit. (c. g., Enter "( ant," (or continuous
<br />...,,.,..Gore. " '° f:.. ,;n: d.°; p_....:c. -I :,~,:: r~, ~.,: d_. Per moc;h. "1 ~r^ -. ..._ :{"'. r riL'artcr, etc ;
<br />U, EOler "harnplr /L'pr' both 8s ~~•tinmPlr 11r~:run~rr.rnl (actual sample npc ,..^.~ •numg nn~nitoring penod) and os
<br />"Permit !b'gmrrnn~nr." (c g , F.ntcr "Groh" for inorcidual sample, "]J//(' for 2~1-hour composite, "A'SI" for
<br />continuous mOnilGiing, clc )
<br />10. Where violations of permit requirements arc reponcd, attach a bnef cxplanauon to describe cause and corrective
<br />actions taken, and reference each violation by date
<br />1. If "no discharge" occurs during monitoring period, enter ",Yo Discharge" across form in place of data entry.
<br />12. Enter "Name/!'itle oJPrincipal Executive O,Tcer" with 'Signature oJPrincipal Executive O~cer oJAuthorized
<br />Agent," "Telephone Number," and "Dale" at bottom of form.
<br />I3. Mail signed Report to Offce(s) by date(s) specified in perntit. Retain copy for your records.
<br />14. More detailed instrnctioru for use of this Discharge ti9oniroring Report (D,L1R) form may be obtained from Office(s)
<br />specified in permit.
<br />Legal Notice
<br />This report is required by law (33 U.S.C. 1318; 40 C.F.R. 125.27). Failure to report or failure to report truthfully can
<br />result in civil penalties not to exceed ~ 10,000 per day of violation; or in criminal penalties not to exceed 525,000 per day
<br />of violation, or by imprisonment for not more than one year, or by both.
<br />EPA Forth 3320-1 (Rev. 08-95)
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