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INSTRUCTIO, POR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTRs 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 �a TP A.c�Y, . TY <br /> 3. Provide dates for beginning and ending in reporting period blocks. 2 <br /> LL <br /> 4. Provide data as specified under column headings. ?.I_L.. 1F i�f i� 1t 4i CF:,iNAC 'RkAT�:-g. af,JAL T'TY z ( .4CY 71 <br /> 5. Enter monthly summary data (MONTHLY AVERAGE,MONTHLY HIGH, etc.). CONTROL 50ARD <br /> 6. Appropriate si nature is required at the bottom of the form. - <br /> q 9 C'� TRAC VALLEY REGION <br /> 7. RemoveeCOPY 3 and retain for your records. m <br /> 8. Send COPY $Ya{FRA,Y2dg96+i.A;.'6 rffFV.aK3.4sEoi?a6d,'(004 N YbX wx.F':: 3?01 S S T R E'E,T i T Y. <br /> SACRAMENTO* CA 55816 <br /> YOUR REPORTING PERIOD IS "'..�L."' AND YOUR REPORTS MUST F` <br /> BE SUBMITTED BY � DAYS FOLLOWING THIS PERIOD. State NPermit <br /> Year Mo. Day Year Mo. Day Code Number <br /> r Year Mo. Day <br /> Transaction Facility Year/Month for Reporting Date form was <br /> Q2 Code LD. "s- ^- I this report I Period: Beginning T t 7-1 Ending �f' 'r �6 .j a,.r' computer printed ft$ 1` � <br /> STATION DESCRIPTION <br /> CONSTITUENT NAME <br /> k. UNITS <br /> SAMPLE TYPE <br /> FREQUENCY <br /> MONTH DAY - s :, _ "P ,: r, .;T <br /> — <br /> _ — - , <br /> — <br /> -- <br /> --- -- <br /> ----- == — ---- -------- <br /> -- — --" �� <br /> --- 1� --------- ------ ----- — --------- ------- ----------- -------- <br /> .-v —. �-._ <br /> "" Is <br /> +.+r r <br /> rte. .-4= Yau <br /> ------------- <br /> --- - -- ------ ,..., — nu. _ .,,. -------- -- ------------ ...y- <br /> --- <br /> " <br /> ------------ <br /> ---------------- <br /> ----------- <br /> - <br /> -- __ <br /> - ----- - ------------ --_- -_ <br /> - <br /> 7 Z7, <br /> --- — -- ------------ <br /> ------------ <br /> - — — —— - <br /> �3 - ---------- ----- - <br /> --- * — _ <br /> N <br /> --- <br /> _ <br /> --- z <br /> --- 1 - - <br /> -77 <br /> --- f <br /> sem z _ -el - <br /> -__ <br /> 1nl <br /> --- <br /> � - 'W <br /> - <br /> ------------ - - -----------t <br /> L"� ���--- L� # �- -- —� -- — <br /> a — <br /> w --- ------ ——————— ------ - ----------- ------- ------- ----------- —————————— <br /> yyy <br /> tMONTHLY AVERAGE <br /> MONTHLY HIGH L3 <br /> MONTHLY LOW U '- <br /> TOTAL RECORDINGS/MO c <br /> REQUIREMENT #1 <br /> Times Exceeded <br /> REQUIREMENT#2 <br /> q <br /> a,� r <br /> Times Exceeded Y k <br /> REQUIREMENT #3 ,u �.. . <br /> s <br /> Times Exceeded " �" "` <br /> Enter number of samples Typed Name of Principal Executive Officer declare under penalty of perjur that the fore oing is true and accurate, and that i <br /> taken Burin the da I' 21 <br /> 9 y. JCO'C'C Darrell � . the sampling procedure and analysis used for t e column constituents was as speci- Siap tare of Principal E.ecutise Yr. Mo. coy COPY <br /> Form 02-9/]4 Last First MI fled in the Waste Discharge Order for this facility. Of liter or Authorized Agent Date <br />