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INSTRUCTH FOR DISCHARGER CALIFORNIA STATE WALiR RESOURCES CONTE, BOARD
<br /> ,. Remove COPY 4 (dark yellow) and use for your n forms.
<br /> DISCHARGER SELF MONITORING REPORT rrc
<br /> 2. Use ballpoint pen or typewriter for data entry on forms. _
<br /> 3. Provide dates for beginning and ending in reporting period blocks. Ja TRACY# CITY OF,
<br /> 4. Provide data as specified under column headings. CALIFORNIA RECTDNAL. WATER OUALTTY <Z .'(.RACY STP'
<br /> CU
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). "Y CONTROL BOARD
<br /> 6. Appropriate signature is required at the bottom of the form, LEhtTL VALLEY 7. Remove COPY 3 and retain for your records. REGION PO BOX 1029
<br /> 8. Send COPY '`gl 'fC,?6�$Is$o'�"r`r�n�' X C�.1t kl' 3P.01 S STREET Zw TRACY
<br /> CALIF I
<br /> 5ACRAWENTOt CA 951516 �0 95376
<br /> YOUR REPORTING PERIOD IS M0N"LY AND YOUR REPORTS MUST �g
<br /> BE SUBMITTED BY FrTl, DAYS FOLLOWING THIS PERIOD. State NPDES Permit FACE 1
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Day
<br /> Q2 TraCodeion F IcDlity 5B39!sI4B I Ye thisM orenth p o r}for 79 Q Reporting ❑ �� Date form was
<br /> /� I Period: Beginning �tPti��! . 1� Ending 79 Ci'�b 3i�f �6 LD-(x9 computer .printed TB u4' Zf3
<br /> STATION DESCRIPTION
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<br /> *Enter number of sample Typed Name of Principal Executive Officer I declare under penalty of er'ur,that the fore oin tF -QAm.
<br /> taken `during the day. $00'tt Darrell l:) P y P I 9 g is true and accurate, and that
<br /> the sampling procedure and ana ysis used for the column constituents was as spec:-
<br /> Form px-9/74 Last First MI Pied.in the Waste Discharge Orderfor this facility. Si ature of Pr c pal Executive Yr. Mo. Day COPYL !
<br /> }f er or Author zed Agent Date f
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