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INSTRUCTIONS R.n DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 1. Remove COPY en or t yellow) andfor use for try onforms. worksheet, DISCHARGER SELF MONITORING REPORT =y _ 3. Use ballpoint pen or typewriter for data entry of forms. J< SEVFhb RFSLIRT' I NC 3. Provide dates for beginning and ending in reporting period blocks. u �1 <. Provide data as specified under calumnheadings. C4L'[FORNIA 'i. GIONAL' SLATER QUALTTY `Z PARADISE POINT MARIN-A S. Enter monthly summary data (MONTHLY AVERAGE. MONTHLY HIGH, etc.). CONTROL »LtARO b. Appropriate signature is required at the bottom of the form. 7. Remove COPY 3and retain for your recards. CENTRAL VALLEY REGION 711 W. KTMr�.FRLY AVEs STF 100 8. Send COPY AIX W xv$(, )Vtlpxxrxrx.xcx;(,Wxotwgxx x x xxx x xx 3443 ROOTIFR ROAD �4PLACI-4T[A .CA SACRAMENTO* CA 95827-3098 FQ9?670 YOUR REPORTING PERIOD IS MONTHLY AND YOUR REPORTS MUST BE SUBMITTED BY FMDAYS FOLLOWING THIS PERIOD. state NPDES Permit PAGr Year Mo. Day Year Mo. Do Code Number Year Mo. Day 2 Tra nSoction I Facility 1 t Year MpIh for /IiT I Rpeomldg Beginning 92 03;7(7)1 Ending 92 03 �1 06 CA.O yI$13 mmtutermr holed `17 Code I.D. 5A39104100 this re ort 7d STATION DESCRIPTION P- R-2 n-3 R_4 CONSTITUENT NAME TOT COLIFORM TOT COLIFOR11 TOT COLIFORM TUT CCLIFORN UNITS MPlifl100ML NPN!10OMI. REIMI00MLtulPN/TOOML SAMPLE TYPE GPAD GRAB GaAB Gif.AS FREQUENCY WFCKLY WEFKLY WFFKLY idFFKLY MONTH DAY _--- __ _____________—------------------------------------ -- -------------------------------- __ --__-__---___ __ -____________ ------------------ ---------------------------------------- _ __________-____ _____________ __ ____.-________ --------------------- _ -_______--_-_ __ -------------- -__-________ __ ____-____-___ __ --_----_-____ __ -____________ __ _____________ 7----� D---- --- 00--------------------------------------------------------- -- ---- -- ------------- -- ----------------------------------- - - -- ------------- ---------------------------------------- ------------ ------------- -- ------------- -- ------------- -- ------------ -- ------------- -- - ---- -- -- ------------- -- ------ -- ------ -- - ------------------------------------------------------------ ------------- ------------- ------------------- ---------------------f------------- -- ------------- --- -- ------------- ------------------------------------- -- ------------- -- ------------- -- ------ -- -------------- -- ------------- -- ------------- - - ------------- -- ------------- --- ----------------- ------------------ -- - -- --- --------- -- ------------ ----------------- ----------------------- --- ---------- ---- �,� -- -------------------------------- -- --------- ------------- ----------------------------------------------------------------- - ------------------ -- ------------- -- ------------- j ---- �� - ------------- ------------------------ ------------- --- ------------------ -------------- --- ------------- ---------------------- -------------- --- �- -- ------------- -- ------------- -- ------- ----------------------------------------- ------------- ----------------------- --------------- ----------------- -- ------------- -- ------------- ---- - - ------------- --- ------------- -- ------------- ------------------------- - ------------------------------------ ---------- ---- -------------------- -- ------------- -- ------------ ------------- zz ---- Z ------------------ ------------------ ----------------- ------------- ---- �� -- ------------- -- ------------- -- -------------- ---- z- ------------------ ----------------- -- ------------- ---- L� -------------- ------------------ ------------------ ----------------------- - -- ------------- ------------------ -- ------------- - ------ ---- -- ------------------ ------------------------------------------ ------------- -- - - ------------- -- -------------- - -------------------- ------------------ ----------------- -- ------------- -< �/ --• ---------------- ---- -- -------------- -- -- - -- ---- -- ------------- -- ------------- ---- -- ---- -- ------------- -- ------------- — ------------- -- ------------- -- ------------- -- ------------- -- ------------- w t MONTHLY AVERAGE / p MONTHLY HIGH MONTHLY LOW TOTAL RECORDINGS/MO. REQUIREMENT #1 Times Exceeded REQUIREMENT #2 Times Exceeded REQUIREMENT #3 Times Exceeded JC Enter number of samples typed Name of Pnnn'pal Ex' cu nve Ofhcer 1 cen Jy u der penalty of low Ihal I hove personally examined ordain familiar with the infor of on submit - r F n led n ndocum 1. and o11 anochni d Ihn. based on my -inquiry of those indimduals edio to ly /� �' � ! (� /� EPA token during the day. /-`F)K' AT,c�)c. re spans ble for ab min ng the nlormoron behove that the n to mal on is true a.cu ate and mmple te.1 pm yc Mo. Doy �FIY aware that there are mgn-12urt penoll es for sol n sn'ng false information. including the passibility of li a Signal ure o neip Esec liv corm a]-e ]a last V First MI and'mpr sonmenL pff icer or Aulhori ed A. Dale