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INSTRM NS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES LvNTROL BOARD 1. Remove COPY 4 (dark yellow) and use for your worksheet. DISCHARGER SELF MONITORING REPORT Use ballpoint pen or typewriter for data entry on forms. 'Y* 1�At- C I TY F 3. Provide dates for beginning and ending in reporting period blocks. 4. Provide data as specified under column headings. L T 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). A L i Y - ACY r'P C 6. Appropriate signature is required at the bottom of the form. c 7. Remove COPY 3 and retain for your records. 1�01;L V t- Ov I! S. Send COPYjZ0�'tlfl P A C,Y C A 1. IF 4giAM 5K X(AT AKC1406',4911c1�00i V,f4:X Ut� Z YOUR REPORTING PERIOD IS AND YOUR REPORTS MUST BE SUBMITTED BY LLJ DAYS FOLLOWING THIS PERIOD. Year Mo. Day State NPDES Permit Year Mo. Day Code Number Year Mo. Day [Q 2] TraCn=ion Yea lot Reprotdi Date form was t nth t FT/ Per, n B 77-77--/�71 Ending Lj /7 1 computer prin ed 7 'acil!ty hr,/�M he p r I I I.D eginning STATION DESCRIPTION CONSTITUENT NAME UNITS SAMPLE TYPE UAW, FREQUENC 7-1 1117 MONTH DAY f C� ----------- -------- % Q t�R'1.11'1�111'1�' ------------ r4 ----------- ------------ ------------I 1�- ------------ --- ------------ ------------ -------7----7 ------ --------- 7�, 7-� --7 7- ------------- r ;7 7, - ----------- "W" ------ ------------ ------------ -------------- --------------- ------------ --------- - 77' 7777 777--------------- -- ------------ -------------- ------------- ------------ ---------- 7 ......... ------------ 7,- -7 -------------- ------------- N "A ------------ -------- 'T' -------- -------- 777, F,,�� ---- ..... - --------------- ------- - ----------- ------ ------------ �'Z ------------ ------------- ------------- ----------- --- ----------- -7 ------------- ---------I--- ------- 4",V's, "'7' _7 7 JIL- ------------ --------------- ----------- - ------------- ----------- - -------------- -------------- -- ------------ "'Zvr�"""rc ---------- - ------------- ------------ ---------- 7 77,7' 5p ------------ 77 '�4 11 ' "' 1, "Ei- 7,,7-' 4 7 LY r"'If '51 cr - - ----- ---- --- -------- 0,",4 ------------- ------------ ------------ ---------- ----------- ------------ ---------------- 7,47 ----------- ------------- - -------- ------------- ---- p 7- p A, ------------- ------------ ------------- ------------ ------ ----- ------------ - - ---------- -------------- -77-777-�,-, 7 --------------- :7------------ ----------- 7-1-7-7-7- 7--- - 7-�-------- --- ------------ -------- tt#�--———————————- -———————————---- ——————————--- --—————————--- cr�--———————— ——————- -—————————— ——————————-- ---———————————- ----------- -I 7-1 ---------------- ---------- art r 'r7, ------------ Z" -- -------- ---- ------------- --------- ----------- ---- - ------------- ----------- ---------- + Morwl-ILY AVERAGE 030 D 3 7�4 0, 9 L/ MONTHLY HIGH // 92- �-8o 4 0�;' MONTHLY LOW 16 a c� 2) 6 ap,8,6 TOTAL RECORDINGS/MO. ti� "r xv REQUIREMENT #1 ""z"m,'"M'U 0"A". "W" Times Exceeded -4 T13 REQUIREMENT #2 Times Exceeded A, REQUIREMENT #3 FTimes Exceeded *Enter number of samples TypLd Name of Principal Executive Offi c ng is true an acci taken during the day. I declare,under penalty of perjur�, that the f recou ' d urate, and that 7�1 ti a samp ing procedure and ona ysis used for the column constituents was as speci- Yr. COPY It ------ f ed in the Waste Discharge Order far this facility. Sirature of Principal Executive Form Q2 9/74 nit, f1cer or Authorized Agent