Appendix G 
AREA

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 MINIMUM AVERAGE MAXIMUM UNITS

 Check here if No Discharge

NOTE: Read Instructions before completing this form

Form Approved.

OMB No. 20XX-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 collection 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 Pennsylvania Ave., NW, Washington, D.C. 20460. 

Include the OMB control number in any correspondence. 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 facility name/ location, if different)," "Permit Number,"

and "Discharge Number" where indicated. (A separate 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 arithmetic average (geometric average for bacterial

parameters) of all sample measurements for each parameter obtained during "Monitoring Period";

"Maximum" and "Minimum" are normally extreme high and low measurements obtained during

"Monitoring Period". (Note to municipals and secondary treatment requirement: Enter 30- day

average of sample measurements under "Average", and enter maximum 7-day average of sample

measurements obtained during monitoring period under "Maximum.") 

6. Enter "Permit Requirement" for each parameter under "Quantity" and "Quality" as specified in

permit. 

7. Under "No Ex" enter number of sample measurements 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 "Sample Measurement" (actual frequency of sampling and

analysis used during monitoring period) and as "Permit Requirement" specified in permit. (e.g.

Enter "Cont," for continuous monitoring, "1/7" for 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 Measurement" (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 requirements 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 monitoring period, check the box for "No Discharge". 

12. Enter "Name/Title of Principal Executive Officer" 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) specified 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 water general permit in New Mexico, Texas, or

Oklahoma do not need approval if they use the correct 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 imprisonment for not more than one year, or by both.