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.STRUCTION- OR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTRG BOARD <br /> f, RemoveUse ballpoint <br /> COPY 4 (dark yellow) and use for your worksheet. DISCHARGER SELF MONITORING REPORT <br /> 2.. Use ballpoint pen or typewriter for data entry on forms. �m <br /> 3. Provide dates for beginning and ending in reporting period blocks. u< RACY,, CITY rF. <br /> 4. Provide data as specified under column headings. C °A I.L F.;.t;♦ " t h K c:Y I;��dR C »°A T.`x e3A L I !'Y. LL RACY S T P <br /> 5. Enter monthly summary data (MONTHLY AVERAGE,MONTHLY HIGH, etc.). P,TR j rw, �n�rT <br /> 6 Appropriate signature is required of the bottom of the fern. C .vrCO CONTROL <br /> R REGION 7. Remove COPY 3 and retain for your records. *,,,f BOX 1f,79 <br /> 8, Send COPYk2(t4>CRAX)KegXrX%,x *4Rai t!6N,3( VCXMXXXX 32?1 S. STR,EFT. zW rPAC.Y "ALIT <br /> SACRAMENT09 CA 95R16 Qo 5376 <br /> YOUR REPORTING PERIOD IS CNV-4LY AND YOUR REPORTS MUST f< <br /> BE SUBMITTED BY ' 't DAYS FOLLOWING THIS PERIOD. State NPDES Permit PACE g <br /> Year Mo, Day Year Mo. Day Code Number Year Mo. Day <br /> Transaction Facilit Year Month for Date form was { <br /> Code ) I.D. y _ 1cI u1 Q9i.�lg ( }his report 7? 1 f Reporting <br /> Beginning 1 <br /> E 9� 9 Ending �6 - ujG�fk computer printed f� ''9 S <br /> STATION DESCRIPTION <br /> CONSTITUENT NAME. qr s;. <br /> M <br /> UNITS <br /> i <br /> SAMPLE TYPE <br /> FREQUENCY <br /> MONTH DAY1 <br /> ov_ <br /> do5& 21 f70199 <br /> ---` L 5 ?-8 <br /> 5 <br /> p <br /> --- 1 41 <br /> r <br /> b� <br /> -13 <br /> --- <br /> '^`K <br /> l� �6 _ � s <br /> �� L � CtO — — --- — '� t � _ rs` �� L _ <br /> — — <br /> --- L 3 <br /> 1 65A0 � - �!` <br /> --- fN' � vary - - � p <br /> 6.3S- — — — <br /> --- t 7a7 ,16 ,4Z - i6 -/0 ----- � -------- <br /> - <br /> - <br /> Z U _a — '+ 3 <br /> a a <br /> >,0 �1, — 6� fU tJ <br /> fz 7 titt� <br /> �� J V`]2 -- - — ----- <br /> t MONTHLY AVERAGES;;,,, <br /> MONTHLY HIGH _O , <br /> MONTHLY LOW /, y$3 !6 2 6`� _ ( Z' <br /> TOTAL RECORDINGS/MO. <br /> REQUIREMENT #1 <br /> Times Exc7 <br /> REQUIREMENT #2 S �� �,� ' <br /> Times Exceeded " ' <br /> REQUIREMENT #3 <br /> - Times Exceeded !; <br /> *Enter number of samples Typed Name of Principal Executive Officer <br /> taken during the day. CO arre 1 I declare under penalty of perjury that the foregoing is true and accurate, and that <br /> D• the sampling procedure and analysis used for the column constituents was as sped- Czr L <br /> Form 03-9p4 last First ml- tied in the Waste Discharge Order for this facility. Signature of Principal Executive Yr. Mo. Day VOPY <br /> Off cer or Authorized Agent Date <br /> i <br />