EPA 6400-01 (OMB 2 NPDES Permittee Data Report Form

OMB Control No. 2080-0021 Approval expires 7/31/2007

United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, D.C. 20460
Laboratory Performance Evaulation
Laboratory DMR-QA Evaluation Study 27
Office of Enforcement and Compliance Assurance
(These data are collected under the authority of the Federal Water Pollution Control Act.)

NPDES Permittee Data Report Form
Permit Extension

NPDES Permit Number

Attention: Follow the instructions on the next
page to complete this form and submit data for
evaluation.
Permittee name
Current Permittee mailing address
City

Zip Code

State

Phone Number

FAX Number

e-mail
For DMR-QA Study 26, conducted in 2006, the Permitee:
Recieved Samples
Yes

Submitted Data

No

Yes

Recieved a Report in Response

No

Yes

No

Certification by Permit Holder or Authorized Representative
(as per 40 C.F.R. Section 122.22 - see instructions.)

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. Each reported
value was produced from a single analytical run using the analytical system that routinely performs these analyses to produce
compliance monitoring data required under our National Pollutant Discharge Elimination System (NPDES) permit. Neither I nor any
of my subordinates compared our results with results from independent analyses conducted by us or any other laboratory before
we reported our results to the U.S.EPA. I am aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment for knowing violations.

Name of Certifying Official

Title

Signature

Date

Address, phone number and e-mail of certifying offical are required if different from above.

Address
City
EPA 6400-01 Rev. 03-07. Previous editions are obsolete.

Phone No.
State

Zip Code

e-mail

OMB Control No. 2080-0021 Approval expires 7/31/2007

United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, D.C. 20460
Laboratory Performance Evaulation
Laboratory DMR-QA Evaluation Study 27
Office of Enforcement and Compliance Assurance
(These data are collected under the authority of the Federal Water Pollution Control Act.)

Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is estimated to average 6.3 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.

Checklist for the NPDES Permittee Data Report Form
Enter your NPDES permit number at the top of page 19 and 21, and where indicated on each laboratory
data sheet you submit for evaluation. Also fill in other Permittee information on page 22.
You must fill in the 2-digit permit extension field at the top of page 19, if there is an extension for your
permit code. If you have one, the extension will appear next to your permit code in the address box on
page 19; for example: “NPDES Permittee MA0102551-01." If there is no extension, leave this field blank.
1. Identify each of your laboratories on pages 21 and 22, including their U.S. EPA Lab code which is a
unique identifier number assigned by EPA. (Refer to page 3, item 4 in the Study 27 packet.) (NOTE:
The U.S. EPA lab code of the laboratory that produced the data must also appear next to each quantity
reported on the data sheets.)
2. Make copies of these three cover pages. Then attach a copy of these pages to the data sheet received
from each laboratory, to create a complete Permittee Data Package. Submit each of these Permittee
Data Packages to the provider who supplied the samples which were analyzed. You are responsible
for submitting data to the various providers to meet your DMR-QA Study 27 reporting requirements.
3. Sign and date the certification statement on page 19.
4. Only use these Permittee cover pages along with the data sheet supplied by each laboratory to report
DMR-QA Study 27 data.
5. Submit the Permittee Data Packages to the providers no later than August 31, 2007.
6. Submit a copy of the data package to your state or Regional NPDES Regulatory Authority.

EPA 6400-01 Rev. 03-07. Previous editions are obsolete.

OMB Control No. 2080-0021 Approval expires 7/31/2007

United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, D.C. 20460
Laboratory Performance Evaulation
Laboratory DMR-QA Evaluation Study 27
Office of Enforcement and Compliance Assurance
(These data are collected under the authority of the Federal Water Pollution Control Act.)

Identification of all CHEM, MICRO and TOX laboratories who did analyses for this permit
Name of Laboratory

Address of Laboratory

U.S. EPA Lab
Code

Lab Analysis
Check box(es) that apply

CHEM

MICRO

Lab Type

TOX

Lab Types: C = Commercial F = Federal G = Local Government I = Industrial O = Other S = State
If you need additional space, please make a copy of this page for additional laboratories.

Print Form

EPA 6400-01 Rev. 03-07. Previous editions are obsolete.