Laserfiche WebLink
INSTRUC..jNS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES C%.,,4TROL BOARD <br /> 1. Remove COPY 4 (dark yellow) and use for your worksheet. <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. < '�.ACY, CITY i2F <br /> 4. Provide data as specified under column headings. r-, t -k I I I V Z <br /> 5 6. Appropriate signature is required at the bottom of the form. 1,A L ACY SI-P <br /> Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). <br /> 7. Remove COPY 3 and retain for your records. Y' <br /> 8. Send COPV7,Ntlli'Xel -i ox <br /> T ACY <br /> Z <br /> T 3 <br /> 376 <br /> RTS MUST <br /> YOUR REPORTING PERIOD lSf"�NT�',LY�AND YOUR REPO <br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. State NPDES Permit <br /> Year Mo. Day Year Mo. Day Code Number <br /> Tty Ye t1or Pe Date form was Year Mo. Day <br /> Q 2] Tran=ion F-11 '01cD athr,'�'or.nt o r Reparlding BeginningE-77TT'J Ending <br /> C computer prin ed FT7, <br /> STATION DESCRIPTION <br /> '�T <br /> CONSTITUENI NAML <br /> UNITS <br /> "... .........*' <br /> SAMPLE - I, 11"'I'll"I'll"I'l;;; <br /> 7' <br /> 77 <br /> FREQUENCY <br /> m <br /> ---- ------- -- ------------- <br /> ----------- <br /> - ------------ <br /> 4-IN -------- <br /> - ————— ———— 77 <br /> r —————— <br /> X ————————— ———————— <br /> —— ————--——-- <br /> r <br /> —————————— 22a' -———"—' �——�—,—"—- <br /> -———————————- <br /> "'ll,--- ——————————-- ——————————— <br /> "4� ———— <br /> --—————————— <br /> ——————————— <br /> ———————————- <br /> ———— --—————————-- z� <br /> "N' "v --- ————— —————- <br /> '7 <br /> ——————————-- <br /> -—————————— - ———————————- <br /> ———————————- <br /> 4...... --—————————— <br /> --—————————— --- - ——— <br /> ——————————-- <br /> Me--7-------1--7- 7---------- <br /> ----- -la ------- <br /> Lo— <br /> ------------- <br /> ----------- <br /> ——— ——————-- -3.11111,-——————————— <br /> ——————————— A — , - '/ l." l <br /> ? <br /> ———————————- - <br /> '4---——————————- <br /> 7 7 '7""77 <br /> 7�7- <br /> 6N, <br /> 4, <br /> A% <br /> , --------- ------- <br /> Al", --- ------ <br /> ----------- <br /> ------------- ----------- <br /> ——————————— <br /> —q, <br /> 77 "114 <br /> --———————— -————— <br /> 't�t' <br /> ——————————— -----I,,- ——————————— ——————————— <br /> ——————————— <br /> -- ———————————-- <br /> -—————- ———Ll <br /> t7',t,'7,——— —————————-- --- <br /> 7", 01�' <br /> "A <br /> ----------- f -'ll -r-'771 <br /> , *�F 4',l " , Z� Z <br /> A, <br /> All <br /> ——— --————————— -- <br /> -——————— —- - <br /> ——————————— -- - ——————————— <br /> 4---————————— <br /> —————— - ———————— <br /> ——————————— <br /> --——————————- <br /> --—————————-- <br /> 7 <br /> T <br /> A41 <br /> 11141 <br /> ----------- -- <br /> ------------ 7 <br /> -- - ------ ------------ ---- <br /> ---------- ----------- <br /> TV ------------ <br /> ---------- <br /> ----------- <br /> ---------- <br /> ' 72 ------------ - <br /> L/ <br /> + MONTHLY AVERAGE ;T� 4, Is- f�q PJ�,-� --� ---� 0, <br /> MONTHLY HIGH 2- 9 ej el,-7 <br /> MONTHLY LOW 13, 3 <br /> 177( <br /> TOTAL RECORDINGS/MO. <br /> 3 1 <br /> REQUIREMENT #1 =X7 _jg�' 7-- <br /> FTimes Exceeded <br /> REQUIREMENT #2 <br /> 771 <br /> F-Times Exceeded <br /> IVA <br /> REQUIREMENT #3 <br /> g 7'7g,'�'�' <br /> Fme, Exceeded <br /> *Enter number of samples Typed Name of 'rincipal Executive Officeq <br /> taken during the day. I declare under Penalty of perjur�, that the foregoing is true and accurate, and that <br /> the sam ling procedur and ana ysis used for the column constituents was as speci- <br /> Forin Q2 9174 Jcott Dermll fied in f e Waste Discho ge Order for this facility. e COPY <br /> ;�T er SiUfature of Principal Executiv Yr. �D <br /> ficer or Authorized Age nt <br />