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INSTRUCTIONS FOR DISC1t ,ER ( IFORNIA STATE WATER RESOURCES CONTROL BO, 1. Remove COPY 4 (dark yellow) and use for your worksheet. DISCHARGER SELF MONITORING REPORT 1 Use olldate pen or typewriter for data t, repot forms.r 6Q 1=.' Ij N Rf SORTS9 INC. ❑� 3. Provide dates for beginning and ending In reporting period blocks. 4. Provide data as specified under column headings. CALIFORNIA REGIONAL ',fAiFR QUALITY <z Pftf'faUISE PAINT MARINA 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH. etc.). CONTROL REGIONAL 6. Appropriate signature is required at the bottom of the form. 7. Remove COPY 3 and retain for your records. CENTRAL VALLEY REGION 711 M• KIMBERLY AVFv STE 200 8. Send COPY �(,R"ARigi9pkxlpKkr)cxx"glxp xxlxxxxx 3443 ROUTIER ROAD --w PLACENTIA •GA SACRAMENTO• CA 45827-'3098 �Q92670 YOUR REPORTING PERIOD IS MAN H Y AND YOUR REPORTS MUST BE SUBMITTED BY Ff5j DAYS FOLLOWING THIS PERIOD. State NPDES Permit PA F Year Mo. Day Year Mo Day Code Number Year Mo. Da 2 TraCodeion I FlcpilY 5839104170 I Yea hisrepoh'fa, I Reporting ' 93 f37 .3� 06 CA004173 Date form was 92 12. I4 �� Penad Beginning9.''i ni -1 End'n com uter rioted STATION DESCRIPTION , CONSTITUENT NAME TOY C(xLIFORM TOY COLIFORM TOT COL [FnRM TOT COLIFIIR� UNITS SAMPLE TYPE r. _ , FREQUENCY CF MONTH DAY 0 / / T J -- ------------- _____________ __ ___ _ __ _____________ ____ __ __ --- ------------- __ ------------- __ —_—___ __ _____________ __ _____________ __ ____ __ ---- -7 -t ---130------ -i -- a-- --- p�---- -1 - --11?D--- -- ------------- - --- -------------- -- ------------- --- -------------- -- ------------- - - ---- - --- -------------- --- -------------- --- -------------- --- -------------- -- ------------- -- ------------- --- ------:-------- -- ------------- -- ------------- -- ------------ - ----------- -- — ---------- -- ------------- -- ------------- --- -------------- ---- t,� -- ------------- -- ------------- --- -------------- -- ---- -- ------------- ------------------- -- ------------- -- ------------- -------- LLGr _--- --------------------------- -- ------------ --- = --- ------------- -- ------------- -- - ------------- -- -- ----------I- -- - ------- -- ------------ -- -------------- -- ------------- -- ------------- -- ------------- ---- -- -------------' -- ------------- -- ------ -- ------------- -- ------------- -- ------------- -- --------------------------------- - _ ------------- -- ------------- -- --- --------- -- --- � - ------------- -- ------------- -- ------------- ---- -- - L3 -- ------------- - - ------------- -- ------------- -- - -------------------------------- -- -- - -------- ---- -- ------------ ---- - -- --- ---------- ----------------- -- ----------------- ----------------- ------------- -- ---- -- ------ -- ------------------ ------------- ---- ------ -- ------------- ---------------------- ------------- I --- -- -- ------------------------------ --------------- ------------------ ----------- --- ------------- -- ------------- -- ------------- -- ---- -- ------------- -- ----------------- ----------------- ------------- --- --------------- ------------------ -- ------------- ------------- -- ------------- - ----------------- ------------- -- ------------- ---- -- ------------- -- -- ---- -- ------------ -- ----------------- ------------- f 1 MONTHLY AVERAGE O D - 490 1 AONTHLY HIGH 13 D 4/0 1599 1 AONTHLY LOW J 3 19 C7 OTAL RECORDINGS/MO. / 'EQUIREMENT N1 Times Exceeded EQUIREMENT N2 Times Exceeded EQUIREMENT #3 Times Exceeded C Enter number of som pies Iyped Nome pl P,mcipal,E eculive Olh<er I cen dyy under penally of low that l have perso"ally eHan ed and am la mihar wnh the in lormohon sub I - led In Ih document and all onr; ,,cats and th 1. basednon my -n qulry of chase nd v'du ols n ,ed ble / taken during the day. /= responsible fa,obm n ng Ih" ,lormcn on I bel eve that the far nal o is true accurate and complete am `� �L COPY aware that there are s gn f cant penalties for sub mi g false Info mahon. ndl d EPA ng the posstb'I ly o!lino Signature al Prinu �ecwiv Yr Mo. Day m O]-9 )a last First MI and im pr somnen L' gif cer oPAW or_r ed Age" Dole