Monthly Monitoring Report (MMR) For Industrial Discharge Permits {30530}

INSTRUCTIONS FOR MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS (State Form 30530) There are three (3) pages to the form, each on a separate sheet (see tabs at bottom). You can specify "Print what: Entire Workbook" under the menu File > Print... to print all three (3) pages and these instructions. Or print each page individually (you must have the page "open" when printing it). General information (Facility Name, Permit Number, etc.) should be entered into the top box on the first page. This information will then show up on subsequent pages of the MMR automatically. If the is no discharge for the month, simply put an X in the box next to "No Discharge" on page 1. Round off the calculated numbers as appropriate when transferring the information to your DMR. Please revise the page numbering as appropriate (eg "Page 1 of 1", etc.). If you wish to use what we've provided as "Page 3" as your first or second page, just change the page info at the bottom. Detailed information and an example of how to fill out the form is available on our web site at http://www.in.gov/idem/5157.htm#owq_wastewater . If only one pH sample is taken per day, either column (Hi or Low) may be used. Many of the cells containing formulas are "locked" to prevent accidental modification. Should you find it necessary to remove the cell protection, the password is "mmr". Should you need to have a geometric mean (rather than an average) calculated, you may unlock the form and change the formula wording in the appropriate cell from "average" to "geomean". American LegalNet, Inc. www.FormsWorkFlow.com MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report State Form 30530 (R3 / 3-14) FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 E-mail address: I N PERMIT NUMBER OUTFALL NO. MO. YR. No Discharge This is a revised submittal EFFLUENT CHARACTERISTICS EFFLUENT PARAMETER NUMBER SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum 03/1/14 15 UNITS = 1 2 3 4 5 6 7 8 9 10 11 T 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE NO. OF TIMES WEEKLY, DAILY, MONTHLY FLOW Q50050 pH C00400 Q C Q C Q C MGD HI LOW LB/DAY MG/L LB/DAY MG/L LB/DAY MG/L EFFL. LIMITATIONS EXCEEDED TOTAL FLOW 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 and evaluate the information submitted. Based on my inquiry of the 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. Prepared by or under the direction of (Certified Operator): Date (month, day, year) Preparer's telephone number Operator's certification number Signature of principal executive officer or authorized agent (or attested by NetDMR subscriber agreement) Page 1 of 3 Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report 0 State Form 30530 (R3 / 3-14) FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 I N PERMIT NUMBER OUTFALL NO. MO. YR. No Discharge This is a revised submittal EFFLUENT CHARACTERISTICS EFFLUENT PARAMETER NUMBER Q SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum UNITS= LB/DAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE NO. OF TIMES WEEKLY, DAILY, MONTHLY C Q C Q C Q C MG/L LB/DAY MG/L LB/DAY MG/L LB/DAY MG/L EFFL. LIMITATIONS EXCEEDED Prepared by or under the direction of (Certified Operator): 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. Based on my inquiry of the 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. Date (month, day, year) Preparer's telephone number Operator's certification number Signature of principal executive officer or authorized agent (or attested by NetDMR subscriber agreement) Page 2 of 3 Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com MONTHLY MONITORING REPORT (MMR) FOR INDUSTRIAL DISCHARGE PERMITS Indiana Discharge Monitoring Report State Form 30530 (R3 / 3-14) FACILITY NAME AND ADDRESS: PLEASE COMPLETE AND SUBMIT ONE COPY EACH MONTH. THIS REPORT MUST BE POSTMARKED NO LATER THAN THE 28TH OF THE FOLLOWING MONTH. Mail To: Indiana Department of Environmental Management Office of Water Quality, Mail Code 65-42 100 North Senate Avenue Indianapolis, Indiana 46204-2251 I N PERMIT NUMBER OUTFALL NO. MO. YR. No Discharge This is a revised submittal EFFLUENT CHARACTERISTICS EFFLUENT PARAMETER NUMBER SAMPLE TYPE Permit Condition Monitored FREQUENCY Permit Condition Monitored EFFLUENT Permit Minimum LIMITATIONS Permit Average Permit Maximum UNITS= 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MONTHLY AVERAGE HIGHEST VALUE LOWEST VALUE NO. OF TIMES WEEKLY, DAILY, MONTHLY EFFL. LIMITATIONS EXCEEDED Prepared by or under the direction of (Certified Operator): I c