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I ' INSTRUCTIONS FGn DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD I r I. Remove COPY 4 (dark yellow) and use for your worksheet 2. Use ballpoint pen or typewriter for data entry on farms. DISCHARGER SELF MONITORING REPORT sFxEN REBORES, INC* 3. Provide dales for beginning and ending in reporting period blocks. r j4. Provide data as specified under column headings. CALIFORNIA REGIONAL' MATER QUALITY LLZPARAOISF P(IINi MARINA 5. Enter monthly summary.data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). CONTROL BOAkO 6. Appropriate signature is required at the bottom of the form. - 7. Remove COPY 3 and retain for your records. CENTRAL VALLEY RFG[ON 711 H. KIMBERLY AVE. STI: 200 8. Send COPY Atit(W.*XFhI(i*.X9XPKX(;('X'NS!9C� Xlkit�XlX9(XXXX .3443 ROUTIER ROAC1 'WPL4CE�lTIA ,CA SACRAMENTO, CA 95827-3098 �Q92670 YOUR REPORTING PERIOD ISI MONTHLY 1AND YOUR REPORTS MUST BE SUBMITTED BY a DAYS FOLLOWING THIS PERIOD. State NPDES Permit PAGE 3 Year Mo. Day Year Mo. Day Code Number Year Mo. Da Transaction Facility Year Month iter (]] Reporting Date term was 2 Code I LD, yR39104100 . 1 Ihisreporl /r �3 I Period Beginning P� il?, "I Ending 92 Q3 3I �6 C40C1P?3 computer rioted STATION DESCRIPTION .-) R-2 RA R-4 P-1 R-2 R-3 R-4 CONSTITUENT NAME ()-' I'•O 111 Uu PH PH PH ('H UNITS MG/L MGIL ."!G/L MG/L SAMPLE TYPE T, TAB GRAB GRAIL GP AS GRAB GRAB GRAB GRAB FREQUENCY MEEKLY WEF.KLY NEFKLY NFEKLY WFFKLY WEEKLY WEEKLY WEFKLY MONTH DAY ----------------------- _____ __--------------- -------------------------------------------------------- —_ -------------------------------- ----------------- ------------ ____________ __ ___________-_____ __ __ _____________ ------------------ ------------------ __ ___---_______ ___------____ __ ___.-___---___ __ _____ __ -__ __________ __ _____________ __ __-_ __------------- -- -------------------------------------------------------- __ -____________ __ _____________ __ __ ____-________ __ __-__________ ---- -- ----- - - - -- - - - - ---------- - -- -- ------------- - - 7 -- ------------- -- ------------- -- ----------- -- --------------------------------------------------- -- ------------- -- ------------- ---- g- -- ------------- -- ------------- -- --------------------------------- ------ -- ------------- ------------------ - ------------- ----------------- -- ------------- -- ------------- -- ti ------------------- - ------------- -- ------------- -- - ------ --- -- ------- ---- -- - ---- ------ -- ----------------- ------------- ---- ,� -- ------------- -- ------------- -- ------------- -- ------------- -- ------------- -- ------------- -- -------------- -- ------------- --- -- -- ------------- -- ------------- -- ------------- ------—-------- - ------------- -- ---—-------------------------- -- ------------- --- — -- ------------- -- ------------- -- ------------- -- ------------ -- ------------- -- ------------- -- ------------- -- ------------- -- ----------------- -- ------------- -- --------------- -- ------------- ---- -- -- ------------- ---- �� -- ------------- -- -- -- ------------- --- -- ------------- -- ---- ------ -- ------------- ---- �� --------------- ----- -- ------------- -- ------------- -- ------------- -- ------------- -- ------------- ---- Z� -- ------------- -- ----`--- ---- Z� -- ------------- - ---- 25 ------------------ ------------------------------------------ -- ---- Zy -------------- ------------------- - ---- Zoo -- -------------- ----------------- -- ------------- ----------------------- --------------------------------------------------- -- -------------- --------------------------- __ __ _____________ __ _____________ __ ______ ______-------------------------------------------------- ______ __ _____________ -------------- ----- ____ _____ w _—__ __ _________ __ _____________ __ _____________ ___—_____—_—_ 3y — -- ------------------ ------------- -- --- - ------------- + MONTHLY AVERAGE t Z5 MONTHLY HIGH 6, y 1 7, '2, 3 MONTHLY LOW v 'J- 71 7• a 7, Y - TOTAL RECORDINGS/MO. / / / if REQUIREMENT #1 Times Exceeded _ REQUIREMENT N2 Times Exceeded REQUIREMENT N3 Times Exceeded iIC Enter number of samples Typed Nome of Principal Ex culrve OIL<er cerrilyy under penally of low that I have aersonally examined and am familar with the formal on sub m _ q es ted -n Ih s document and all anachmenls and that based an y m quay of those individuals med only ` •� �� .��1 P' �y �oL EPA taken during the day. FAf. Y j-'i11�fC l� r.spc sbid for obranng tha nfarmwon Ibeleve that the lormaton-s true accurate andmmplet. lam ^^� aware that there are s gAl'carl penal es for subm'nbg false Information. including the poss bitty of Imp Sig nature of Prl ipol E ecuriv v*- Mo. Day co , Form 019 r� Last First MI and'm prisonm enl.' Officer or Authorized Agent. Date