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INSTRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD
<br /> 1. Remove COPY 4(dark yellow) and use for your worksheet. DISCHARGER SELF MONITORING REPORT
<br /> 2. Use ballpoint pen or typewriter for data entry on forms.
<br /> 3. Provide dates for beginning and ending in reporting period blocks. J� RACY* CITY OF
<br /> 4. Provide data as specified under column headings. -L I FCR N I A R E GV�N AL �OA T�E R QUA L f'i Y <iRACY STP
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE,MONTHLY HIGH, etc.).
<br /> 6. Appropriate signature is required at the bottom of the form. C CIN I R rl B CIAR D
<br /> 7. Remove COPY 3 and retain for your records. _1TRAL VALLEY REGION 0 b0X 1029
<br /> 8. Send COP*%Y015" XXXX X S STRE_%�T z RACY CALIF
<br /> SACRA4ENTCt CA 9581& 5-176
<br /> YOUR REPORTING PERIOD IS��044tHLY�AND YOUR REPORTS MUST
<br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. State NPDES Permit PAGE
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo: Day
<br /> Q72TraCn=ion 'a Ye or Reporting F7,7-j�
<br /> I F-1 I C DT'y I th(P'orenp a r t' Beginning _7 Date form was
<br /> Period: I Ending I computer printed 7 9 he
<br /> STATION DESCRIPTION
<br /> CONSTITUENT NAME UNITS
<br /> SAMPLE TY E
<br /> FREQUENCY
<br /> MONTH DAY 7 03�)C 00095
<br /> 6c4
<br /> 2- 2 ------------
<br /> 7IM-7
<br /> �7
<br /> '7� 71',�,7 7 777-7777/ 7
<br /> 747,7,
<br /> ............ '71. 7 777M,7
<br /> IL 4",
<br /> -2-0-1------- ----------- ----------- -- -------- -----------
<br /> ,,7,, 777777777
<br /> ----------- ----------- ------------ -----------
<br /> 7777757,7,70,-77777. —,d,7N1YT7" I -
<br /> 7, 7, 7777,_
<br /> .................
<br /> 7
<br /> 7,7 77,775 77,
<br /> 77
<br /> 4
<br /> 12-
<br /> �,t,tM."'
<br /> 7,171 71,311=" 177,777,71, r�7
<br /> ----------- ----------- ------------
<br /> �7 7- ----------- ------------
<br /> Al
<br /> ----------- ------------ ------------
<br /> 77,,�,77,7' 777 �77
<br /> ''R 7Z57,0,Y 77,777R,7Z 7KEY-5,
<br /> 11 ",
<br /> IR 1-11
<br /> 19,211y
<br /> ----------- ----------- ----------- ----------- ----------- -----------
<br /> 77. 755R MF,77, ,77*77,77", 7R,777,-7,77-
<br /> 777,- 77M�,',77,
<br /> ME,, 77,7 77, 7
<br /> .........
<br /> v,
<br /> ----------- ----------- ----------- ----------- ----------- -----------
<br /> 6", -- & 1 t I
<br /> ......1- �01004Q I'm
<br /> �77,-,7,7177,04,3757;77,,�-,,r
<br /> N"'I"W."
<br /> 2S*"
<br /> �A,
<br /> ----------- ----------- ----------- ------------ ----------- ------------ ------------ ---------- -
<br /> ----- ----------- ------------ ----------- ----------- ------------
<br /> ------------
<br /> + MONTHLY AVERAGE 2-o2- 0,
<br /> MONTHLY HIGH .167 .2�i 0
<br /> MONTHLY LOW
<br /> __fOTAL RECORDINGS/MO.
<br /> REQUIREMENT #1
<br /> REQUIREMENT #2
<br /> [ Times Exc eded
<br /> REQUIREMENT #3
<br /> L F-Tim—esExcee—ded
<br /> *Enter number a I samples Typed Name of Principal-Executive Offlice, I declare under penalty of perjurr, that the fore�oing i's true and accurate, and that �S�11
<br /> ---11 t /3
<br /> taken clurin the day. scoi-i- Dar e he sampling procedure and anoysis used for t e column constituents
<br /> M f 'in
<br /> Form 02-9/74 Lost Firs. MI fied in the Waste Discharge Order .r this facility. S ,v r r a .a r f Principal Execultive Yr. e Day
<br />
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