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INSTRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD
<br /> ,. Remove COPY 4 (dark yellow) and use for your worksheet. DISCHARGER SELF MONITORING REPORT
<br /> 2. Useballpoint pen or typewriter for data entry on forms. L, R.A.CY9 CITY IF
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<br /> 3. Provide dates for beginning and ending in reporting period blocks, v [E'�F�t1f 1 A �f�' ��,^dA E R,a T '. :':iAi.I TY RACY STP
<br /> s 'Provide data as specified under column headings. LL
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). CrjN TR£1L B UARO I
<br /> 6. Appropriate signature is required at the bottom of the form. r ('RAC VALLEY fN E GI UN 0 F3GX I P29
<br /> 7. Remove COPY 3 and retain for our records. I
<br /> B. Send eoPXx 6d( Sdf d(fWEt6 'MOMV,XfiXXXX i S STRFET" zp RACY Al l
<br /> of+,K.AMINT"D, CA 93275 Qo "'3-976
<br /> YOUR REPORTING PERIOD IS" '7 4 LY AND YOUR REPORTS MUST Ea
<br /> BE SUBMITTED BY -I DAYS FOLLOWING THIS PERIOD. state : NPermit PACE
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Day
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<br /> t MONTHLY AVERAG s '
<br /> MONTHLY HIGH _
<br /> MONTHLY LOW
<br /> TOTAL RECORDINGS/MO.
<br /> REQUIREMENT #1 '
<br /> Times Exceeded
<br /> REQUIREMENT #2e`'
<br /> Times Exceeded r��� a � e
<br /> REQUIREMENT #3 s ®, �'" Wyss >•"Sis r ,W
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<br /> T ed Name of Principal Executive Offer A
<br /> Enter dumber of 'samples YP P I declare under penalty of perjury that the foregoing is true and accurate, and that
<br /> taken during The day. he sampling procedure and analysis used for the column constituents was as sped, Si nature of Prnnclpo� Executive Y,. Mo. Day COPY "
<br /> Form Q2 9/74
<br /> Last First MI ied in the Waste Discharge Order for this facility. �fficer or Aath.h., Agem Date 9
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