/ Sub-sector L3Discharge Monitoring Report
Industrial Stormwater Program
Doc Type: Discharge Monitoring Report

Instructions: Unsigned, incomplete forms will be returned.

  • Type/sign and date the form.
  • Please provide a sample date and sample results or check the “no flow” box if no flow occurred during the entire sample period.
  • For sample results, only record one set of results per form.
  • Print as many copies of this form as necessary to provide results from multiple sample dates/locations within this period.
  • Sample dates outside of this period will not count for this period.
  • Do not make any changes to form. To make a change, please fill out the Industrial Stormwater Change Form(wq-strm3-60) found on the Minnesota Pollution Control Agency website at

Submittal: Send the completed form by the 21st day of the month following this reporting period to:

Email: - or- / Mail:Stormwater Monitoring Report, Minnesota Pollution Control Agency
520 Lafayette Road North, St. Paul, MN 55155-4194

Sub-sector L3: Landfills discharging to surface waters

Facility name / Facility address / Facility ID number / Sample date (mm/dd/yyyy) / Sampling year
Enter conditions existing at the time sample was taken:
Station# / Station name / If no flow occurred during the entire monitoring period, place an X in the box below. / If sample was not collected within 30 minutes of start of the event, place an X in the box below.
Parameter / PCS code / Limit / Units / Sample value
Solids, Total
Suspended (TSS) / 88 mg/L daily maximum / mg/L
27 mg/L calendar month average / mg/L
Nitrogen, Ammonia
Total (as N) / 10 mg/L daily maximum / mg/L
4.9 mg/L calendar month average / mg/L
BOD, Carbonaceous
05 Day (20deg C) / 140 mg/L daily maximum / mg/L
37 mg/L calendar month average / mg/L
Phenol / 0.026 mg/L daily maximum / mg/L
0.015 mg/L calendar month average / mg/L
Zinc,
Total (as Zn) / 0.20 mg/L daily maximum / mg/L
0.11 mg/L calendar month average / mg/L
pH / 6.0 SU, instantaneous minimum / SU
9.0 SU, instantaneous maximum / SU
Alpha-Terpineol / 0.033 mg/L daily maximum / mg/L
0.016 mg/L calendar month average / mg/L
Benzoic acid / 0.12 mg/L daily maximum / mg/L
0.071 mg/L calendar month average / mg/L
p-Cresol / 0.025 mg/L daily maximum / mg/L
0.014 mg/L calendar month average / mg/L

Certification

By typing or signing my name below, I certify the above information to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form.

Authorized representative (Owner/Operator)

Print name: / Title:
(This document has been electronically signed if emailing.)
Signature: / Date (mm/dd/yyyy):
(Sign this form if mailing hard copy.)

651-282-5332 or 800-657-3864•Available in alternative formats

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