Appendix F DMR Form

Appendix F

PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
NAME

NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)

Form Approved.
OMB No. 20XX-XXXX
Approval expires XX-XX-XX

DISCHARGE MONITORING REPORT (DMR)
(2-16)

(17-19)

ADDRESS
PERMIT NUMBER

MONITORING PERIOD
Check here if No Discharge
DAY
YEAR MO
DAY
FROM
TO
NOTE: Read Instructions before completing this form
(20-21) (22-23) (24-25)
(26-27) (28-29) (30-31)
QUANTITY OR LOADING
(4 Card Only)
QUALITY OR CONCENTRATION
NO. FREQUENCY
YEAR

FACILITY
LOCATION
(3 Card Only)
(46-53)

PARAMETER
(32-37)

AVERAGE

DISCHARGE NUMBER

MO

(54-61)

MAXIMUM

UNITS

(38-45)

(46-53)

MINIMUM

AVERAGE

(54-61)

OF
ANALYSIS
(62-63)
(64-68)
EX

MAXIMUM

UNITS

SAMPLE
TYPE
(69-70)

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
NAME/TITLE PRINCIPAL EXECUTIVE OFFICER

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.)

TYPED OR PRINTED
COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)

EPA Form 3320-1 (10-96)

TELEPHONE

SIGNATURE OF PRINCIPAL EXECUTIVE
OFFICER OR AUTHORIZED AGENT

(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.)

AREA
CODE

NUMBER

DATE

YEAR

PAGE

MO

OF

DAY

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.