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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. "Acyt CITY 0F <br /> 4. Provide data as specified under column headings. At, A 11'�' RACY STP <br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). T;' ��'"'A 1 <br /> 6. Appropriate signature is required at the bottom of the form. ',L L!.-,Y 029 <br /> 7. Remove COPY 3 and retain for your records. A L V J FOX <br /> r�ALY CALIF <br /> 8. Send COP'VZth,,�Kk, Ketl4irKrSqmrF hb4c*b*)k1(=P'KX 16X-;�,KXX��t 4 r ­ 1 <br /> Z <br /> A <br /> 5376 <br /> YOUR REPORTING PERIOD isF-'7-'4r-jLY �AND YOUR REPORTS MUST <br /> r-_--1 -- I <br /> BE SUBMITTED BY DA�S FOLLOWING TI-115 PERIOD. State NPIDES Permit <br /> Tra Ye for Year Mo. Day Year Mo. Day Code Number Date form was Year Mo. Day <br /> 7 -6] computer printed <br /> 02] Cn=ion a t R e p a r.ldm..g <br /> 'aci'ity t hr(P'orenot a r Peri Beginning 1 Fo <br /> I I.D Ending <br /> STATION DESCRIPTION A <br /> CONSTITUENT NAME <br /> UNITS <br /> SAMPLE TYPE <br /> FREQUENCY N <br /> �-" W, A, <br /> MON H DAY <br /> ---- -------------- ------------- ------------ ------------- -- ------------- ----------- ----------- ------------ <br /> 7 <br /> 77 _7 <br /> ----------- - ----- -------- -1-1---------- <br /> ------------- ------------ - ----------- ----- ------- -------------- <br /> `,J <br /> M 77........ <br /> --- -------- <br /> 7 ------- -- --------7--- -- ------------- <br /> ----------I-- 7,�--- ---------- <br /> ""Z <br /> 77 <br /> m ------- <br /> x Mm <br /> EHE <br /> ----------- <br /> �n <br /> 7 7 <br /> "I-- ------------ - ----------- <br /> -2- -1��------ <br /> 9 <br /> ----------- <br /> ----------------- - ------------ -- <br /> ------------ ----- ------ <br /> ';'�x �,:72 =7'7,, -77,,,T,,7 71, <br /> '4, "1 <br /> 7 <br /> L <br /> S77 <br /> "2 --Z6-------I <br /> "IM <br /> "44 <br /> -------------- ----------- ------------ <br /> ------------ ------------- ----------- -------------- ----------- <br /> - ---------- ---- <br /> 41.1 <br /> ------------ - ---------- -------------- <br /> ------------ 7- <br /> 77� <br /> ----------- <br /> 7- <br /> 7, <br /> ---------- ------ ------------ <br /> 77 <br /> j---- L4 2 ------ <br /> V ------------- - <br /> - ------------- -------- ------------ <br /> -------- �,'7-�,77 7 <br /> T,�7 7' <br /> �7 <br /> ——--——————— ——————————— 11'��— —————— <br /> ————————--- ——————————-- <br /> -j-x' <br /> ——————————— ———————————-- <br /> ——————————— <br /> ----—————————— ——————————- <br /> n",11N, <br /> "X, <br /> -———————————- - <br /> 4,11 ————————— <br /> --—————————- <br /> ---------- -- - ------- <br /> N <br /> oL" -" , , I I <br /> - ---------- <br /> -1- ------------ -------- <br /> ------------- ------------ ------------- ------------ ------------- - ------------- <br /> w, <br /> ----------- <br /> ----------- <br /> ----- ------ - <br /> ------------- <br /> ----------- ----- ---------------- <br /> ------------- ------------ ------------ <br /> -2------- <br /> - -- -------- <br /> A 19 _2 ----- - <br /> + MONTH'LY'AVE RAGE ' <br /> 21 <br /> MONTHLY HIGH 7, -7 a <br /> MONTHLY LOW 7 ,-7 ;Z / c� <br /> TOTAL RECORDINGS/MC. <br /> REQUIREMENT #1 <br /> Times Exceeded <br /> REQUIREMENT #2 <br /> FT,mes Exceeded <br /> 7- <br /> REQUIREMENT #3 <br /> *Enter number of samples Typeed Nome of Principal Executive Office, I declare under penalty of perjurf, that the forening is true and accurate, and that <br /> taken during �e day. the sating procedure and ona ysis used for t a column constituents was as speci <br /> M, tied in t e Waste Discharge Order for this facility. of Principal'E;-ecu�ive�' jDy <br /> MI <br /> Form Q2 9/74 Lost no or Authorized Agent, c, <br /> Sluff., <br />