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— T STRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD
<br /> 1. Remove COPY 4 (dark yellow) and use for your worksheet. =w
<br /> 2. . Use ballpoint pen or typewriter for data entry on forme. DISCHARGER SELF MONITORING REPORT
<br /> 3. Provide dates for beginning and ending in reporting period blocks. ua TRACY* CITY OF
<br /> 4. Provide data as specified under column headings. f,ALIF')ikNIA P,EGI",?R1AL WA7Eq QUAL ITY 'Z TRACY STP
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). L & A r r: 17
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<br /> VALLEY +`LC S 1CtN PC, box 1 .29
<br /> 6. Appropriate signature is required at the bottom of the form. GDNTfV
<br /> 7. Remove COPY 3 and retain for our records. CF-4TRAL
<br /> B. Send COPY'd%fo'CEgR�Q,7��Yg' 1k,$i4+XFMoY�B`isXoKdKd4 XXoZ(3(�F. lf'k3F#lE "D1 S ST RFE'T ZwTRACY CALIF .
<br /> SACRA?MENT7v CA 95816 <t 95376
<br /> YOUR REPORTING PERIOD IS Pl'J TNLY AND YOUR REPORTS MUST sa
<br /> BE SUBMITTED BY [1`51 DAYS FOLLOWING THIS PERIOD. State NPDES Permit PAGE
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Da
<br /> Q2 TraCn=ion Facility SB aC+1fiiA Y1 Year/ --tor}for 79/071Re orcin Y
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<br /> MONTHLY LOW ,c1/C) �� 76��,�- L x
<br /> Ih TOTAL RECORDINGS/MO. /Z
<br /> REQUIREMENT #1
<br /> Times Exceeded
<br /> REQUIREMENT#2
<br /> REQUIREMENT #3
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<br /> qEnter number of samples Typed Name of Principal Executive Officer I declare under penalty of perjury that the foregoing is true and accurate, and that 7 / e�
<br /> taken during the day. Baker John W the sampling procedure and analysis used for the column constituents was as speci- �.
<br /> Form Os-9/74 last First MI tied in the Waste Discharge Order.for this facility. Signature of P rincipal Executive Yr. Mo, DayY
<br /> Officer or Authorized Agent Date
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