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TN-5...JCTION5 FOR D15CHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD <br /> 1 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 TRACYTr CITY OF <br /> � CALIFIORNTA REGIONAL WATER QUALITY TRACY STP <br /> 3� AYtRA(51z, MONTHLY HIUH, etc. <br /> 6. Appropriate signature is required at the bottom of the fo.rm. CONTROL 80ARD <br /> 7. Remove COPY 3 and retain for your records. C�NTRAL VALLEY REGION PO BOX IOZ9 <br /> 8. Send COPY XX"X)eVJ6)(X,XXrXV&UXc"X KOW)4)(oXX XX XXX X <br /> 3201 S, STREET z-. TRACY LALIF <br /> SACRAMENTOv CA 95eI6 m� 95376 <br /> YOUR REPORTS MUST <br /> YOUR REPORTING PERIOD ISFMCINTHLY :E Q< <br /> BE SUBMITTED BY R-5-1, DAYS FOLLOWING THIS PERIOD. State NPDES Permit PAGE <br /> Tron=ion Y e a r Year Mo. Day Year Mo. Day Code Number Year M Do <br /> r(�A--th f Pp <br /> Re orting Date form was <br /> I C 'acil!ty er,.d. 78 06 15 <br /> Q72 LD I th report Beginning F71R/�09��l Ending computer prin ed <br /> STATION DESCRIPTION <br /> CONSTITUENT NAME <br /> UNITS <br /> SAMPLE TYPE <br /> FREQUENCY <br /> MONTH DAY 70300 70 30 0 00095 .. ..... <br /> 70507 Wo!iOl I <br /> ------------ <br /> 7,7' <br /> ,t4 <br /> - ------- - - <br /> ----------- ----------- <br /> ----------- ----------- <br /> ----------- -- <br /> 6 ------------ <br /> 7, 777777 7- <br /> 9 <br /> ----------- ----------- -------- <br /> ----------- --- ------------ <br /> A <br /> 77-V ;7 <br /> 77777,7,7,77 7777,`�7,,7-7' <br /> -7 <br /> 7 777,1777, <br /> ----------- ---------- ----------- <br /> 7 <br /> _5 7,1-7 <br /> L2 <br /> ---------- - ----------- ----------- ---- <br /> t <br /> 117 <br /> ---------- <br /> a --3-L-(------- ----------- ----------- <br /> 7 �7- 57R, 7, <br /> ,77, 77,,�,77 R',Z,50 <br /> 7-------- <br /> --/------- ----------- - ----------- ----------- <br /> ---------- --- <br /> 7�77 711, 717,11-7,17,11,11,11, <br /> 77,`70 <br /> 7 7,,,,7 <br /> 1 11 z 44 1-1411 <br /> I <br /> < ------- ---- ------ - <br /> ----------- ----------- ------ <br /> - ------------ ------------- <br /> ----------- ----------- ---- <br /> I I <br /> AGE <br /> Y �IGH <br /> m.NTILI LOW A <br /> TOTAL RECORDINGS/MO. <br /> -FE-Q—UIRE <br /> mqini <br /> MENT # g a <br /> Times Exceeded 119 <br /> REQUIREMENT #2 <br /> Times Exceeded <br /> J� REQUIREMENT #3 <br /> *Enter number of samples Typed Name of Principal Executive Off c. <br /> taken during the day. i��I declare under penalty of perjurr, that the foregoing i's true and accuote, a d thatl 7i�j 13 E�� <br /> scott Darrell D Ithe sampling procedure and ana d for the column constitu-...- as a speci <br /> ysi5 Use SiKature of Principol Executivv Yr. Mo Day <br /> 1.,a,�Q29111 Lost First MI tied in the Waste Discharge Order far this facility. ficer or Authori,sd Agen,e Date flow <br /> L ------ <br />