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<br /> INSTRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATIIER RESOURCES CONTROL BOARD
<br /> 1. Remove COPY 4 (dark yellow)and use for your worksheet.
<br /> 2. Use ballpoint pen or typewriter for data entry on forms. DISCHARGER SELF MONITORING REPORT
<br /> 3. Provide dates for beginning and ending in reporting period blocks.
<br /> U< RACYj CITY �-,F
<br /> 4. Provide data as specified under column headings.
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.�. CALIFORNIA PEGIONAL '4AIER QUALITY RACY STP
<br /> 6. Appropriate signature is required at the bottom of the form. CONTROL BOARD
<br /> 7. Remove COPY 3 and retain for your records. CENTRAL VALL�LY RIECION 0 5OX 1029
<br /> & send S STREET z RACY CAt IF
<br /> --------]AND YOUR REPORTS MUST L�91RAMIENT(lv CA 05014, 5376
<br /> YOUR REPORTING PERIOD ISFJ74TRLY N
<br /> BE SUBMITTED BY r_r__1
<br /> DAYS FOLLOWING THIS PERIOD. State NPIDES Permit P A G E_
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Day
<br /> Q72 TroCn=ionF_j1 Facil!ty Ye or Rgort�ing
<br /> 7 r. -T-1 Ending Date form was
<br /> D WMonpth BeginningF7
<br /> STATION DESCRIPTION th re art computer printed
<br /> CONSTITUENT NAME
<br /> UNITS
<br /> SAMPLE TYPE
<br /> FREQUENCY
<br /> MONTH DAY 310
<br /> 7 ,77,77 ,97,
<br /> 7*7� 73R
<br /> 7,77, 7'7,,-`,,
<br /> ........... .
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<br /> _32
<br /> n 1 '-/ 1-7 _��T Y4-----
<br /> w+ EMtONTHLY AVERAGr' 1 3 2 sr_ L2 ;
<br /> �I_� - ) R
<br /> MONTHLY HIGH / , -7
<br /> MONTHLY LOW 7
<br /> TOTAL RECORDINGS/MO.
<br /> FEQUIREMENT #1
<br /> Times Exceeded 13
<br /> 11
<br /> REQUIREMENT #2
<br /> Times Exceeded
<br /> REQUIREMENT #3
<br /> Times Exceeded
<br /> *Enter number of som e of Principal Executive Officerl
<br /> taken during the day. Scott Darrell I declare under penalty of perjurr that the foregoing is true and accurate and that
<br /> the sa%ing procedure and ana ysis used for the column constituents wo as speci- CS( 7� 1 '2�n i
<br /> Form Q2-9/74 Last First M, fied in t e Waste Discharge Order for this facility. SkL , of P,in,:,.�-�t-.1!4 Y'. Mo. Do, Py
<br /> er or Authorized Agent Date
<br />
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