5600-FM-BMP0487 Rev. 11/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
SHEET 1--NPDES TOXICS (TABLE III) MONITORING REPORT
Report values in micrograms/liter. Insert “X” for those parameters which are not expected to be present. Applicable to Mine Drainage Treatment
Facilities and Storm water Discharges.
Operator:
Operation Name:
Mining Permit No.:
NPDES Permit No.:
Township:
County:
Outfall ID
Date
Sampled
Sb, Total
As, Total
Be, Total
Cd, Total
Cr, Total
Cu, Total
Pb, Total
Hg, Total
Ni,
Total
Se, Total
Ag, Total Tl, Total mg/l
Zn,
Total
Cyanide,
Total
Phenols, Total
Note: Method Detection Lower Limits should be reported as “less than” values for those results not detected. For example, if the MDL for a test is 0.05 ug/l and
the constituent is not detected, report < 0.05 ug/l.
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5600-FM-BMP0487 Rev. 11/2015
Sheet 2--NPDES TOXICS (TABLE IV) MONITORING REPORT
Insert “X” for those parameters which are not expected to be present. Insert “DMR” for those parameters that have been submitted with DMRs.
Applicable to mine drainage treatment facilities and storm water discharges.
Outfall
ID
Outfall
ID
Outfall
ID
Outfall
ID
Date
Sampled
Date
Sampled
Date
Sampled
Date
Sampled
Br, Total
Chlorine, Total
Res
Color
Fecal
Coliform F, Total
Nitrate-Nitrite
N
N, Total
Organic
Oil & Grease
P, Total
Radioactivity
SO4, Total
Sulfide
Sulfite
Surfactants
Al,
Total
Ba, Total B, Total
Co, Total
Fe, Total
Mg, Total
Mo, Total
Se, Total
Sn, Total
Ti, Total mg/l
Br, Total
Chlorine, Total
Res
Color
Fecal
Coliform F, Total
Nitrate-Nitrite
N
N, Total
Organic
Oil & Grease
P, Total
Radioactivity
SO4, Total
Sulfide
Sulfite
Surfactants
Al,
Total
Ba, Total B, Total
Co, Total
Fe, Total
Mg, Total
Mo, Total
Se, Total
Sn, Total
Ti, Total mg/l
Br, Total
Chlorine, Total
Res
Color
Fecal
Coliform F, Total
Nitrate-Nitrite
N
N, Total
Organic
Oil & Grease
P, Total
Radioactivity
SO4, Total
Sulfide
Sulfite
Surfactants
Al,
Total
Ba, Total B, Total
Co, Total
Fe, Total
Mg, Total
Mo, Total
Se, Total
Sn, Total
Ti, Total mg/l
Br, Total
Chlorine, Total
Res
Color
Fecal
Coliform F, Total
Nitrate-Nitrite
N
N, Total
Organic
Oil & Grease
P, Total
Radioactivity
SO4, Total
Sulfide
Sulfite
Surfactants
Al, Tot
Ba, Total B, Total
Co, Total
Fe, Total
Mg, Total
Mo, Total
Se, Total
Sn, Total
Ti, Total mg/l
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5600-FM-BMP0487
Rev. 11/2015
Sheet 3--NPDES TOXICS (TABLES II & V) MONITORING REPORT
Report values in micrograms/liter. Provide data for Table II parameters that are expected to be present. Provide any available data for the Table V
parameters.
If the site meets the small business exemption (SBE), data for the Table II parameters is not required. If SBE Applies Check here:
If there are no parameters from Table II that are expected to be present check here:
If you have no data for the Table V parameters check here:
Outfall
ID
Date
Sampled
Parameter:
Parameter:
Parameter:
Parameter:
Parameter:
Parameter:
Parameter:
The Tables are available at this link: http://www.gpo.gov/fdsys/pkg/CFR-2011-title40-vol22/pdf/CFR-2011-title40-vol22-part122-appD.pdf
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Parameter:
5600-FM-BMP0487 Rev. 11/2015
Sheet 4--NPDES Monitoring Report--Other Parameters
All of the following are required for stormwater facilities (40 CFR 122.26(c)(1)(E)).
Provide a description of the storm event (date, duration and precipitation amount) related to the sample.
Those marked with an asterisk “*” are required for treatment facilities (40 CFR 122.21 (k)(5)(vi)-Form 2C).
This data is representative of the following facilities with substantially identical effluents:
Constituent
Reported on DMRs
Waived
Result
*pH
*Total Suspended Solids (TSS)
*Chemical Oxygen Demand (COD)
*Biochemical Oxygen Demand (BOD)
*Ammonia (NH3)
*Total Organic Carbon (TOC)
*Flow
*Temperature (high)
*Temperature (low)
Oil and Grease
Total Phosphorous
Total Kjeldahl Nitrogen
Nitrite-Nitrate Nitrogen
Are Dioxins expected to be present?
No
Yes, provide quantitative data for TCCD
.
I certify under penalty of law that I have personally examined and am familiar with the information submitted herein, based on my inquiry of those individuals immediately responsible
for obtaining the information, I believe the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment.
Signature of Permittee or Responsible Official or Authorized Representative
Date
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