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INSTRUCTh FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTk BOARD <br /> 1. Remove COPY 4 (dark yellow) and use for your worksheet F <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, ua t f A CY i CITY <br /> F <br /> 4. Provide data as specified under column headings. to c'rt s q< t / a 'Y }�.s �,.jn 'f I r v 'I^'Y Q� ",JJ <br /> i.� ACY STP I <br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). <br /> b. . Appropriate signature is required at the bottom of the form. <br /> 7. Remove COPY 3 and retain for your records. Y "rj3 (a,J BUi.,( T2 <br /> 8. Send COPY 7,Ib A(AtiblbiC P,,;$db G{stfo'(d�(N$(APy,XA°pX XX X . ".'*" . T iw 7R A[Y 1 A F_I V <br /> 9 t;376YOUR REPORTING PERIOD IS �4''"T'HS.Y AND YOUR REPORTS MUST fa <br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. State NPDES Permit <br /> Transaction Facilit Vear Month for Year Mo. Day Year Mo Day Code Number Year Mo. Day <br /> -! y r / Reporting Date form was i <br /> Q? Code I D rl I this report J1T Period Beginning Ending ; g �6 computer printed t <br /> STATION DESCRIPTION <br /> :CONSTITUENT NAME. <br /> UNITS4, <br /> SAMPLE TYPE <br /> FREQUENCY <br /> MONTH DAY 1„ IQ3 ...;t <br /> -------- *+nww«er; , y ..... _i✓< .... ,w«»aczus.w, _. .,.—? u —_ � « — — '— � <br /> -- <br /> ' > ——— _ ---_ — — " -- ----` _ �-- -- e`^t <br /> . ----- <br /> -- <br /> —_ <br /> -- 1 <br /> ---- �i -- t t - <br /> --- -1 <br /> -= <br /> -� - - - - -- <br /> --- _ ' r - - --- <br /> r 14 <br /> 1 <br /> --- / - - - - - - ��s1 _ <br /> If, - cz <br /> y yY <br /> — e+ - y/ — g• M• — fL <br /> --- LL —=- � — - — — Y. <br /> -- -- -- — — ---- <br /> --- ! 2 --- 1 — <br /> < � I <br /> --- 1 — — — — — 4 — — -- _mac t --- <br /> _1_ — --- _�5°_ L <br /> k <br /> f 7 <br /> - - c53�i <br /> - - - - 1za <br /> Icy <br /> --- - 1 _ ra_ _ t - <br /> u: 1 <br /> .- - <br /> L / --vL`v i _ fe" r _ _._ .-- —.e.._ _ __ _ <br /> A–. , } r11111GI I, '1 <br /> 1 <br /> " --- a <br /> 1.1 <br /> Y --- -- <br /> Q --- L ———— <br /> — ———— <br /> ———— <br /> --- -- --- -- — w -- --�(� ---- <br /> U <br /> 1.. <br /> t MONTHLY AVERAGE 1A0 -6 <br /> MONTHLY HIGH <br /> MONTHLY LOW � <br /> TOTAL RECORDINGS/MO. 2 .210 <br /> REQUIREMENT #1Ivv, <br /> Times Exceeded <br /> REQUIREMENT #2 <br /> i <br /> Times Exceeded <br /> REQUIREMENT #3 <br /> * Times Exceeded <br /> *Enter number of samples Typed Name of Principal Executive Officer I declare under penalty of perjury that the foregoing is true and accurate, and that AA <br /> taken during the day. n the sampling procedure and analysis used for the column constituents was as specs- �' r - ' 1 3 2 I <br /> Last First MI fied in the Waste Discharge Order for this facility. sig tare of Principal Executive Yr. Mo. Day COPY <br /> Form Q2-9/74 Officer or Authorized Agent Date <br />