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li STRUCTIONS FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTROL BOARD
<br /> ,. Remove COPY 4 (dark yellow) and use for your worksheet. G REPORT
<br /> 7 DISCHARGER SELF MONITORIN
<br /> Use ballpoint pen or typewriter for data entry on forms. �aITR ACY t CITY `sat.
<br /> 3. Provide dates for beginning and ending in reporting period blocks. Z
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<br /> 4. Provide data as specified under column headings. CALIFORNIA REG1,0NAL. ''AATcQ ')UALI TY LLTRACY STP
<br /> 5. Enter monthlysummary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). CONTROL BOARD
<br /> 6. Appropriate signature is required at the bottom of the form. CE V'TRAL VALLEY REGION PO BDX 1L 9
<br /> 7. Remove COPY 3 and retain for yo�u�r records.
<br /> 8. Send COPY X X,�„XGrXlXa6YLXd*KX(XI X)fiiXXXA'XX XX :3201 S STREET iw TRACY 4AL.IF
<br /> SAC
<br /> RAMENTOt CA 95816 895376
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<br /> YOUR REPORTING PERIOD ISMOvfNL—Y ANDYOUR REPORTS MUST
<br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD, State NPDES Permit
<br /> r ® Year Mo. Day Year Mo. Day Code Number Year Mo. Day
<br /> Transaction Fa cilit Yea r�Mo nth for Reporting - �. Date form was
<br /> Q2 Code I I.D. Y r?$ 9C 1�JLT1 this report 7 d I Per'od Beginning77771
<br /> Ending t 06 T`9 L. +tr computer printed
<br /> STATION.DESCRIPTION og
<br /> CONSTITUENT NAME
<br /> UNITS
<br /> SAMPLE TYPE
<br /> FREQUENCY
<br /> a
<br /> MONTH DAY T030C IU3095 D0400 61482 315 'IS C 5
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<br /> f ! 5 _6� �---- ----- ---- -- -------
<br /> 2.6 4 --- 172 Kiii O r T4
<br /> t MONTHLY AVERAGE I)71A 0r .` J
<br /> MONTHLY HIGH (3 a2 oL/ 2
<br /> MONTHLY LOW /d,a2 Le. 12-5, `` F <
<br /> ` TOTAL RECORDINGS/MO. 2 12— (¢�+
<br /> ',,h.,'`.�yrv° s� Zvk
<br /> REQUIREMENT #1 Yh �� sv `�f��w>'^
<br /> 4 k$rq`'�'M "" y ,s''x iew"nas"'`.Z,i, so « " '< a s ✓i h x 3
<br /> Times Exceeded
<br /> REQUIREMENT #2 <.n, y .. � g. ai"r�L
<br /> Times Exceeded
<br /> REQUIREMENT #3
<br /> I a:�;�yr tis xw��A.i"', ;a�. �r `"v�✓ n� 2 :' .. .;. r u ' v u= 'a�vn ^�v^a�
<br /> J IIT�1 5 ` tw; k s• a Vit,h r syvas F y 1a
<br /> .Times Exceeded 0Mys,� ,;`` 1,�ss,,,; „„,,, „^?,a,,,;” ,^. ^,., ^ _< ,. ,
<br /> *Enter number of samples TYPed Name of Principal Executive Officer declare under penalty of perjury that the foregoing is true and accurate, and that
<br /> taken during the day. ak- John the sampling procedure and analysis used for the column constituents was as speq sg nature of Pnnupoi Execut,ve Yr. Mo. Day COPY L
<br /> Form 04-9/74
<br /> Last First MI Pied in the Waste Discharge Order for this facility. - Officer or Authorized Agent Date q
<br /> —_vim.
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