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____________________
(gallons per day)
Measured
Maximum daily flow volume____________________
(gallons per day)
Monitoring Point_____________
Measured
No discharge or
Average daily flow volume____________________
(gallons per day)
Maximum daily flow volume____________________
(gallons per day)
Estimated
Estimated
Not applicable
Measured
Measured
Estimated
Estimated
Daily flow volumes are used, in part, to determine self-monitoring and reporting frequencies. Reported
values, especially estimates, must be as accurate as possible.
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C. BATCH DISCHARGES
Section C 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 applicable
or
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.
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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 Name
Volume
Ship Date
Hauler 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 Representative
____________________________________________
Name (please print or type)
___________________________________________
Title (please print or type)
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_______________________
Date
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 Representative
____________________________________________
Name (please print or type)
____________________________________________
Title (please print or type)
Periodic Compliance Report (SIU)
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_______________________
Date
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 Representative
____________________________________________
Name (please print or type)
____________________________________________
Title (please print or type)
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_______________________
Date
REVISION #
1
REVIEWED/REVISED BY
Jane Gowing/Kathie Upchurch
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REVIEW/REVISION DATE
December 31, 2010