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STRUCTIOP. OR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTRi. BOARD
<br /> 1. Remove 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. 4RACY
<br /> R ACYL CITY F
<br /> 3. Provide dates for beginning and ending in reporting period blocks.
<br /> 4. Provide data as specified under column headings. CALIFOONIA I,,- ?: '>v}A L. IiATFR QUALITY SIP I
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). CONTROL E3 U'A (}
<br /> b. Appropriate signature is required at the bottom of the form. C`'VTRAL VALLEY REGION 0 FIOX 1.G"':-9
<br /> 7. .Remove COPY 3 and retain for your records. 3t i T S STREEI ip RACY CALIF
<br /> e. SendCOP1Dy.5.C'W)Et�i;Re`§i6rKA',�d6 b6r6dEdbJk+Xr�' Pl'C'A2GdCIfXX, . 53 6
<br /> SACRA"ENT"D• CA 95PI6 <a
<br /> YOUR REPORTING PERIOD IS ONTHLY AND YOUR REPORTS MUST PA
<br /> BE SUBMITTED BY DAYS FOLLOWING THI5 PERIOD. State NPDES Permit
<br /> i Year Mo. Day Year Mo. Day Code Number Year Mo. Dny,
<br /> Year Month for Reportin Date form was
<br /> j Transaction Facilityg 1, Endin B hit �6 wL�ggS. com uter rinted
<br /> Q2 Code I LD. -.. 39ti1Ct8f3Y this report -J I I Period Beginning rF 9 P P
<br /> STATION DESCRIPTION
<br /> CONSTITUENT NAME.
<br /> UNITS .r
<br /> ! SAMPLE TYPE i
<br /> FREQUENCY
<br /> MONTH DAY C'?
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<br /> MONTHLY HIGHz I
<br /> MONTHLY LOW A, 3I
<br /> TOTAL RECORDINGS/MO c] I
<br /> REQUIREMENT #1 `'rye-., 7 h fi, ,g
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<br /> Times Exceeded ,rsOil I
<br /> REQUIREMENT#2 , > qY s �' yr Y s »��, ;� "
<br /> Times Exceeded ? ` "'
<br /> r� REQUIREMENT#3
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<br /> y Typed Name of Principal Executive Officer
<br /> *Enter number of samples YP P I declare under penalty of perjury that The foregoing is true and accurate, and that r - r '
<br /> taken during the day. Darrell D the sam ling procedure and analysis used for the column constituents was as speci- L
<br /> p Si norore of Pr nc pal Ezecutiv Yr. Mo. Day
<br /> Form Q2-9/74
<br /> Last First MI fied in the Waste Discharge Order for this facility. �tfi<er or Amhori:ed Agenr Date
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