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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.
<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. ',z CITY F
<br /> 4. Provide data as specified under column headings. CALIFORNIA REGIONAL WATFR ",-JAL11Y -iPACY S I P
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). CONTROL 5CARD
<br /> 6. Appropriate signature is required at the bottom of the form.
<br /> 7. Remove COPY 3 and retain for your records. CENTRAL VALLEY REGION
<br /> 8. Send COPY ZwEPAK KA 1,11 S STREET 0z 4,C Y C A L i�
<br /> jtfRA,%iFNTCi CA -15?16 3
<br /> YOUR REPORTING PERIOD lSf7�4THLY AND YOUR REPORTS MUST :E
<br /> BE SUBMITTED BY r--. ] DAYS FOLLOWING THIS PERIOD. Year Mo. Day State NPDES Permit PAC t
<br /> Year Mo. Day Code Number Year Mo, Day
<br /> F6_2] TraCn=ion[71 Facil!ty Ye !Aonplh for R e p:�,rot din g f,� /�, /7-1 Date form was
<br /> or' re 0't Per BegirmingE-7-771
<br /> I.D th, Ending computer printed
<br /> STATION DESCRIPTION
<br /> CONSTITUENT NAME
<br /> UNITS
<br /> ----------
<br /> -----------
<br /> SAMPLE TYPE "g
<br /> &W
<br /> FREQUENCY
<br /> MONTH DAY
<br /> ------------ -----------
<br /> LL
<br /> 0
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<br /> 2,
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<br /> + MONTHLY AVERAGE -7 C,i C2, P\ek�, 0� 3 9
<br /> MONTHLY HIGH 13 _7� Y J/0 0
<br /> MONTHLY LOW /(j ey F�S- (:�)-,"D 4 3 n. 2-
<br /> TOTAL RECORDINGS/MO. L/ 3 / 3 1-
<br /> REQUIREMENT #1
<br /> Times Exceeded 111M,�
<br /> IP
<br /> REQUIREMENT #2 "S'ff, ff ffff, fg-
<br /> �f; if,�,I"",f�,�ffpj �-,fg'-,f,;f,f,�,�;ff�-"�,�,,,,,,,g"ffff"f"�"ff�;."�kff",f�f",f Lf'�,"frU040 AN 2`f�,I,111fw,
<br /> Times Exceeded
<br /> REQUIREMENT #3
<br /> 1-1 N,-
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<br /> eded I,
<br /> Times Exce
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<br /> *Enter number of samples ryLe_d Name of Principal Executive Offi I declare under penalty of perjur�, that the fore�omg is true a ac rate, and that
<br /> I ( , ,, �t -I 2E
<br /> ta ken duri, the day. h ling procedure and ana s used for t e column con it en was as speci- ry
<br /> Tied in Tre Waste Discharge Orderys.i tij,� f P incipal' Executive PY
<br /> form 02-9/74 Lost Fh, M1 r this facility. cer or Arth orized A�W
<br />
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