Use This Form to Document Annual Loads, Where Required by the Permit, for Situations Where

3800-FM-BPNPSM0448 3/2012COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
TMDL SUPPLEMENTAL REPORT
ANNUAL LOAD SUMMARY
Facility Name:For Annual Period: to
Municipality:County: NPDES Permit No.: Outfall No.:
Watershed: Renewal application due 180 days prior to expiration
This permit will expire on
MONTH - YEAR / Parameters
(Total Monthly lbs) / (Total Monthly lbs) / (Total Monthly lbs) / (Total Monthly lbs) / (Total Monthly lbs)
Total Annual Loads:
I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel 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 Pa. C.S. § 4904 (relating to unsworn falsification).
Prepared By: / Signature:
Title: / Date:
3800-FM-BPNPSM0448 Rev. 3/2012
Instructions / COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
INSTRUCTIONS FOR COMPLETING
TMDL ANNUAL LOAD SUMMARY
SUPPLEMENTAL REPORT

Use this form to document annual loads, where required by the permit, for situations where annual load limits are based on an approved Total Maximum Daily Load (TMDL). However, where a permit contains annual load limits for Total Nitrogen and/or Total Phosphorus based on the Chesapeake Bay TMDL, use the Nutrient Monitoring, Monthly Nitrogen Budget, Monthly Phosphorus Budget, and Annual Nutrient Summary forms for reporting (3800-FM-BPNPSM0444, 3800-FM-BPNPSM0445, 3800-FM-BPNPSM0446, and 3800-FM-BPNPSM0447, respectively).

Enter Facility Name, Municipality, County, Watershed No., Annual Monitoring Period dates, NPDES Permit No., Outfall No., and Permit Expiration Date.

Enter parameter names (e.g., Total Suspended Solids, Total Phosphorus, etc.) in the table below the header "Parameters." For each month, enter the Total Monthly Mass Loads.

Type the name of the person who prepared the form, the person's job title, and sign and date the form after reading the certification statement.