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INSTRUCTI( FOR DISCHARGER LAILIFORNIA STATE WATER RESOURCES CONTRC 30ARL
<br /> 1. Remove COPY 4 (dark yellow) and use for your worksheet.
<br /> Use ballpoint pen or typewriter for data entry on forms. DISCHARGER SELF MONITORING REPORT j-'< TRACYv CITY OF
<br /> 3. Provide dates for beginning and ending in reporting period blocks. 'Z
<br /> CAIL-If�GRNIA RE-GIONAL WATEP QUALITY TRACY STP
<br /> �5. �En7,;r�-mo�n-t.h-ly-s.u'm'm.-a;.riy-�do-t-o�(-M'-O-'N-T-H�LYb.A-VERAGE, MONTHLY HIGH, etc.). CONTROL BOARD
<br /> 6. Appropriate signature is required at the bottom of the form. CENTRAL VALLEY REGION PQ BOX 1029
<br /> 7. Remove COPY 3 and retain for r records.
<br /> 8. Send Copy XXdWX*yjrPXXQXIK**X<XCAX X"XXXX XX XXXX 3201 S STREET TRACY CALIF
<br /> SACRAMENTOl CA 95816 )5376
<br /> YOUR REPORTING PE YOUR REPORTS MUST
<br /> iRIOD ISFMCNlTHLY
<br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. State NPDES Permit
<br /> Tra Year Mo. Day Year Mo. Day Code Number Date form w Yeor'Ao. Day
<br /> Q72 Cn=ion Ye at nth or R;portdin..g as
<br /> E777) I er�'0 B computer printed
<br /> thi'�Morepert' eginning F78/07/7)11 Ending
<br /> STATION DESCRIPTION
<br /> X
<br /> 1W
<br /> CONSTITUENT NAME
<br /> K"�'Mc,Z
<br /> Ull,
<br /> SAMPLE TYPE
<br /> "K
<br /> FREQUENCY
<br /> MONTH DAY 70300 1 70300 1 03095 00095 1 0060 5 6 C 5 70501 70507
<br /> ------------ ----------- ----------- ----------- ---------- ------- ------- -----------
<br /> 7,=
<br /> 777
<br /> . ......
<br /> V
<br /> ----------- ----------- ----------- ----------- ------------ - ----------- ----------- ------------
<br /> 330 5yo
<br /> 7 7-, 7:7 7, 47 ---------- -7,7r'
<br /> 7,5
<br /> 77 U4, 7 �7,7,077,7: 77 '7777,77,--7 7777 -j7477 77 '777-77�'�
<br /> "4 ..... .......
<br /> 44"'it''
<br /> ------------ ----------- ----------- ----------- ----------- ----------- ----------- ------------
<br /> /0 '-J 3?0 57
<br /> , 74"�4,7,,
<br /> 11-11 771111411"', 7,77,7,7, 7777,7, 777 77,7,7` 7'
<br /> 77
<br /> 12.
<br /> ----------- ----------- ----------- ------------ ------------ ------------
<br /> 777-7,7,rM7 77,77,7777
<br /> N7 77 7,,777- 77777-j
<br /> 1Z
<br /> ----------- ----------- ----------- ----------- ------------
<br /> ----------- ------------
<br /> 'T 7",,7-,-, 777777;7-
<br /> ----------- ----------- ----------- ----------- --------- ----------- -------------
<br /> 7' -17 7 ',.7
<br /> 7f 777,7',� 7,,7- ',,777,,-;',' 7,77-77, 7',, 777- 47,,77
<br /> Q
<br /> K
<br /> ----------- ----------- ----------- ----------- -----------
<br /> 774,77
<br /> -77' -7,77, 7,v7;"7'- 7, 77,=,7,
<br /> 774, 7-,7
<br /> al
<br /> 6"m
<br /> 177a ==7'�'
<br /> A
<br /> ------------
<br /> A9
<br /> ----------- ----------- ----------- ----------- ------------
<br /> 4 0 -- - ----- ----------- ----------- -----------
<br /> ,I'll I �4 -- --- ----- --------- ------------
<br /> L-1 -[--- '51- 11 y Q, S 7
<br /> f 1� AVERAGE ' 'j // 1/-Z v ?sil
<br /> y Sq
<br /> Y
<br /> �M.�14 T�1 LLY �1.V/ 3 ol- �11
<br /> TOTAL RECORDINGS/MO.
<br /> REQUIREMENT #1
<br /> e of—e
<br /> Times Exce d
<br /> REQUIREMENT #2
<br /> Times Exceeded
<br /> REQUIREMENT #3 vasemn, "10, KEN 11211,11111"
<br /> '401111 OR-
<br /> gyy
<br /> WRM
<br /> Times Excppdpcl
<br /> J� Typed Name of icerl
<br /> tEnte 2nber of samples Principal Executive Off I declare under penalty of perjur� that the foregoing is true and accurate, and that EPA
<br /> r u
<br /> to ken du ri n g the day. DA rrp.11 the sam ling procedure and ano ysis used for the column constituents was as speci-
<br /> Last First fied in Te Waste Discharge Order for this facility. Slyfature of Principal Executive Yr. Mo. D;y COPY
<br /> Mi ficer or Authorized Agent Date
<br /> L —--------
<br />
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