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INSTRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATER RES01CIS CONTROL 8tARD <br /> i. 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. o� TRACY, CITY OF <br /> 4. Provide data as specified under column headings. CALIFORNIA REGIONAL WATER QUALITY <Z TRACY STIR <br /> 5. Enter monthly summary data (MONTHLY AVERAGE,MONTHLY HIGH, etc.). CONTROL BOARD <br /> 6. Appropriate signature is required at the bottom of the form. CENTRAL VALLEY REGION P13 EOX 1029 <br /> 7. Remove COPY 3 and retain for your records. 0. <br /> .oWX)RAWA X)04rXF Z., <br /> 8. Send COPYNY A*X0(cXc*XMWXX(XXXXXXXX 3201 S STREET TRACY CALIF <br /> SACRAMENTOt CA 95elb 95376 <br /> :in I <br /> YOUR REPORTS MUST < <br /> YOUR REPORTING PERIOD 15'FMOWTHLY State NPDES Permit PAGE, <br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. <br /> Tro Year Mo. Day Yea r Mo. Day Code Number Date form was Year Mo. Day <br /> Q72 Cn=ion FacDility Yea nth 'or R e p o ro,in g Ending I computer prin ed <br /> I r(P'0 Per BeginningF7E97511 <br /> I NXIM I It report <br /> STATION DESCRIPTION <br /> xx ISMS I <br /> CONSTITUENT NAME <br /> UNITS <br /> SAMPLE TYPE <br /> FREQUENCY <br /> MONTH DAY 70300 0 00400 61402 3 05 1 500co 00552 <br /> _7. Zj— 3 <br /> -Sfat_-A ——————————— ——————————— 0————— ——————————— ——————————-- <br /> ----------- ----------- ----------- <br /> 6. 5, -77,777 77, <br /> 77,'�,77' <br /> 7 77 <br /> ...... " <br /> 4�i "'JI, ��" —"7, ,,, <br /> 7 7 <br /> 77,77,, <br /> n""Ar <br /> —————--————— -————— <br /> —————————— ——————————— —————— -- --——— <br /> 77 <br /> ,777 <br /> F/ 77 <br /> 7, tJ ------ <br /> 7, =77 '7 <br /> 777 <br /> R <br /> ----- ------- ----------- ----- <br /> 4 <br /> ",',77' <br /> ——————————— ——————————— ————————— — ——— --————— <br /> 2- <br /> 7 <br /> 7 <br /> ——————————— ————————— — ... ---4p>————— —————-a———— <br /> S TO <br /> al" <br /> .2 1? <br /> cc <br /> C) <br /> ——————————— ——————————— ——— ——————————— -- --L——— -——————- <br /> K ————— ——————C)———— ————————— <br /> ———— ——————————— ———— —————— ——— — ———-- ------------- <br /> + MONTHLY AVERAGE <br /> 2-V 0 '/Oc) o 2—C) <br /> MC)NIZZLI �I.Vl 2— a 3 <br /> TOTAL RECORDINGS/MO. C� <br /> REQUIREMENT #1 <br /> REQUIREMENT #2 <br /> REMENT #3 <br /> MIA <br /> "QU, <br /> *Enter number of samples Typed Name of Principal Executive Officeril declare under penalty of perjurr, that the for%ing-� true and accurate, and that <br /> taken during the day. ec, Sivature of Principol Executive Yr. M�L jDy <br /> M <br /> ,rell D I the samrling procedure and ono ysis used for t e col�mn constituents was as sp f ?'�4 <br /> fied in t e Waste Discharge Order for this facility. icer or Aut h orized Agent Do,. <br /> r Form 029/74 <br /> L <br />