PERIODIC COMPLIANCE REPORT
Periodic Compliance Reports are due on or before the last day of the month following the end of the reporting period and must be submitted to the address(es) listed in the "Reporting Requirements for Permittee" section of your wastewater discharge permit. Not all of the sections listed below apply to all permittees. Some permittees may also need to submit information in addition to the items appearing on this checklist. Consult your wastewater discharge permit for your specific reporting requirements.
Reporting period from______to______
Date prepared______Phone______
Prepared by______
A.FACILITY INFORMATION
Name______
Location______
______
Phone______Fax______Emergency______
B.FLOW MONITORING
Flow monitoring information may be required for more than one Monitoring Point. Attach additional sheets as necessary.
Monitoring Point______No discharge
Average daily flow volume______Measured Estimated
(gallons per day)
Maximum daily flow volume______Measured Estimated
(gallons per day)
Monitoring Point______No dischargeor Not applicable
Average daily flow volume______Measured Estimated
(gallons per day)
Maximum daily flow volume______Measured Estimated
(gallons per day)
Daily flow volumes are used, in part, to determine self-monitoring and reporting frequencies. Reported values, especially estimates, must be as accurate as possible.
C.BATCH DISCHARGES
SectionC applies to process waste batch discharges.
Monitoring Point______No batch discharge
Number of batch discharges______
Batch discharge log attached
Analytical results, if any, attached
D.PRODUCTION INFORMATION
Not applicableor Production data attached
E.SAMPLING RESULTS
Attach copies of the analytical results of all samplings, including split samplings, at the Monitoring Point(s) specified in Section B of the discharge permit, performed by the permittee or any other agency during the reporting period, and not on file with the Metro District. Analytical results submitted with this Periodic Compliance Report must contain the following information:
1.Concentrations and measurements of all parameters for which there are self-monitoring requirements.
2.The date, time and location of all sampling activities. Include the start-stop dates and times for all time- or flow-proportioned composite samples and the flow documentation for all flow-proportioned composite samples.
To avoid self-monitoring reporting errors or violations, the analytical results included in this report should also contain the information listed below for all samples. At a minimum, this information must be kept on file for at least 3 years and be available for inspection.
3.The method of sampling (grab, time composite, flow composite, instantaneous or continuous measurement) and name of the person collecting the sample.
4.The name of the laboratory (or person) that performed the analyses.
5.The date the analyses were performed.
6.The analytical techniques/methods used for the analyses.
7.Flow data and documentation, including (where applicable) charts, recordings, meter readings, logs, and/or other reported flow values.
F.WASTE DISPOSAL
Attach copies of disposal records for wastes hauled off-site for disposal or recycling during the reporting period, or provide a summary of waste disposal activities in the space provided below, or indicate "no activity" if no wastes were disposed of during the reporting period.
No waste disposal activity occurred during the reporting period
Disposal record copies attached
Waste NameVolumeShip DateHauler Name
______
______
______
______
______
______
G.EYEWASH CERTIFICATION STATEMENT
Not applicable, or Not true
If not true and if not currently on file with the Metro District, attach a description of each instance of compliance monitoring event(s) during eyewash discharge and the exact date(s) of the discharge and monitoring event.
or,
"Based on my inquiry of the person or persons directly responsible for managing compliance with the pretreatment standards for this facility, I certify that, to the best of my knowledge and belief, there was no eyewash discharge during any compliance monitoring event."
______
Signature of Authorized RepresentativeDate
______
Name (please print or type)
______
Title (please print or type)
H.CERTIFICATION STATEMENT FOR TOTAL TOXIC ORGANICS
Not applicable, or Not true
If not true attach a description of each instance of concentrated toxic organics dumping, the exact date(s) of the discharge, and the corrective action implemented to prevent recurrence and to comply with the toxic organic management plan.
or,
"Based on my inquiry of the person or persons directly responsible for managing compliance with the permit limitation for Total Toxic Organics, I certify that, to the best of my knowledge and belief, no dumping of concentrated toxic organics into the wastewaters has occurred since filing of the last discharge monitoring report. I further certify that this facility is implementing the toxic organic management plan submitted to the control authority."
______
Signature of Authorized RepresentativeDate
______
Name (please print or type)
______
Title (please print or type)
NOTE TO SIGNING OFFICIAL: In accordance with Title 40 of the Code of Federal Regulations, Part 403, Section 403.14, effluent data provided in this PCR shall be available to the public without restriction. Any other information provided may be claimed as confidential by the submitter. Such claim must be asserted at the time of submission by stamping the words “Confidential Business Information” on each page containing confidential data or information, or similarly identifying the information claimed as confidential. Requests for confidential treatment of information shall be governed by procedures specified in 40 CFR Part 2.
I.ACCURACY AND COMPLETENESS CERTIFICATION STATEMENT
"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. I further certify that there are no significant and/or regulated industrial process operations being conducted at this facility which discharge wastewater to the POTW and which are not covered by this report. 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."
______
Signature of Authorized RepresentativeDate
______
Name (please print or type)
______
Title (please print or type)
REVISION # / REVIEWED/REVISED BY / REVIEW/REVISION DATE1 / Jane Gowing/Kathie Upchurch / December 31, 2010
Periodic Compliance Report (SIU)Page 1