# Appendix GAREA CODE YEAR MO DAY

NAME/TITLE PRINCIPAL EXECUTIVE OFFICER YEAR MO DAY PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) NAME

ADDRESS

FACILITY LOCATION NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) DISCHARGE MONITORING REPORT (DMR)

(2-16) (17-19)

PERMIT NUMBER DISCHARGE NUMBER

MONITORING PERIOD

FROM TO (20-21) (22-23) (24-25) (26-27) (28-29) (30-31) (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION (46-53) (54-61) (38-45) (46-53) (54-61) AVERAGE MAXIMUM UNITS AVERAGE MAXIMUM UNITS MINIMUM Check here if No Discharge
NOTE: Read Instructions before completing this form Form Approved. OMB No. 20 XX

- XXXX Approval expires XX

- XX

- XX

NO. EX (62-63) FREQUENCY

OF ANALYSIS (64-68) SAMPLE

TYPE (69-70)

TELEPHONE DATE

NUMBER YEAR MO DAY

EPA Form 3320-1 (10-96) (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)

TYPED OR PRINTED I CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS WERE PREPARED UNDER MY DIRECTION OR SUPERVISION IN ACCORDANCE WITH A SYSTEM DESIGNED TO ASSURE THAT QUALIFIED PERSONNEL PROPERLY GATHER AND EVALUATE THE INFORMATION SUBMITTED. BASED ON MY INQUIRY OF THE PERSON OR PERSONS WHO MANAGE THE SYSTEM, OR THOSE PERSONS DIRECTLY RESPONSIBLE FOR GATHERING THE INFORMATION, THE INFORMATION SUBMITTED IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR KNOWING VIOLATIONS. SEE 18 U.S.C. § 1001 AND 33 U.S.C. § 1319. (Penalties under these statutes may include fines up to $10,000 and or maximum imprisonment of between 6 months and 5 years.) SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT

SAMPLE MEASUREMENT

PERMIT REQUIREMENT PARAMETER (32-37)

## PAPER WORK REDUCTION ACT NOTICE The public reporting and recordkeeping burden for this colle ction of information is estimated to average 24 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Penn sylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondenc e. Do not send the completed form to this address.

GENERAL INSTRUCTIONS 1. If form has been partially completed by preprinting, disregard instructions directed at entry of that information already pre-printed. 2. Enter "Permittee Name/Mailing Address (and facilit y name/ location, if different)," "Permit Number," and "Discharge Number" where indicated. (A s eparate form is required for each discharge.) 3. Enter dates beginning and ending "Monitoring Period" covered by form where indicated. 4. Enter each "Parameter" as specified in monitoring require- ments of permit. 5. Enter "Sample Measurement" data for each parameter under "Quantity" and "Quality" in units specified in permit. "Average" is normally arit hmetic average (geometric average for bacterial parameters) of all sample measurements for eac h parameter obtained during "Monitoring Period"; "Maximum" and "Minimum" are normally extrem e high and low measurements obtained during "Monitoring Period". (Note to municipals and se condary treatment requirement: Enter 30- day average of sample measurements under "Average" , and enter maximum 7-day average of sample measurements obtained during moni toring period under "Maximum.") 6. Enter "Permit Requirement" for each paramet er under "Quantity" and "Qua lity" as specified in permit. 7. Under "No Ex" enter number of sample m easurements during monitoring period that exceeded maximum (and/or minimum or 7-day average as appropriate) permit requirement for each parameter. If none, enter "0". 8. Enter "Frequency of Analysis" both as "Sampl e Measurement" (actual frequency of sampling and analysis used during monitoring period) and as "Pe rmit Requirement" specified in permit. (e.g. Enter "Cont," for continuous monitoring, "1/7" fo r one day per week, "1/30" for one day per month, "1/90" for one day per quarter, etc.) 9. Enter "Sample Type" both as "Sample Measurem ent" (actual sample type used during monitoring period) and as "Permit Requirement", (e.g. Enter "Grab" for individual sample, "24HC" for 24-hour composite, "CONT" for continuous monitoring, etc.) 10. Where violations of permit r equirements are reported, attach a brief explanation to describe cause and corrective actions taken, and reference each violation by date. 11. If "No Discharge" occurs during monitori ng period, check the box for "No Discharge". 12. Enter "Name/Title of Principal Executive Office r" with "Signature of Principal Executive Officer or Authorized Agent", "Telephone Number", and "Date" at bottom of form. 13. Mail signed Report to Office(s) by date(s) specif ied in permit. Retain copy for your records. 14. More detailed instructions for use of this Discharge Monitoring Report (DMR) form may be obtained from Office(s) specified in permit. 15. Facilities using the digital form of the DMR must first obtain approval from the NPDES authority in their state. The parameters and data on the form must be mono-spaced (e.g. Courier) and have a size of 10 pitch (12 points). Approval for EPA Region 6 can be obtained by contacting Cathy Bius at (214)665-6456. Permitees holding a storm wate r general permit in New Mexico, Texas, or Oklahoma do not need approval if they use the co rrect type as specified above. THE FORM MAY NOT BE ALTERED IN ANY MANNER.

LEGAL NOTICE 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 result in civil penalties not to exceed $10,000 per day of violation; or in criminal penalties not to exceed $25,000 per day of violation, or by impr isonment for not more than one year, or by both.