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' NSTRUCTII . FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTRA BOARD
<br /> Remove COPY 4 (dark yellow) and use for your DISCHARGER SELF MONITORING REPORT =W
<br /> l Use ballpoint pen or typewriter for data entry onn forms.
<br /> Provide dates for beginning and ending in reporting period blocks u¢ TRACY' CITY f'
<br /> a. Providedata asspeafied under column headings. t TfC?R rd 1A P` .t _ , 3 )-v 1 LLZ TRACY tT1'
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). ` ..rr�N TREyt `J '+A , .,) 4. {
<br /> b. Appropriate signature is required at the bottom of the form. r^QTR AL. VALLEY Y G,J
<br /> 7. Remove COPY 3 and retain for your records. C E r r.i 3fiX j.:;.7y
<br /> 8. Send COPY IfaSPA,:Ra'gipMR,X9lfd{F.�'d K d6bGXCfXXXoXXXX 3201 S STREET " T
<br /> z p R A Y CALIF. '.
<br /> SAr' AMSNT'7y. CA 5158,16 453
<br /> YOUR REPORTING PERIOD IS MtJNTHIY AND YOUR REPORTS MUST f°
<br /> BE SUBMITTED BY DAYS FOLLOWING THIS PERIOD. State NPDES Permit
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Day
<br /> Q? TraCodeion Falc'Dlity Year/Month for Re orcin = 06 Date form was
<br /> ❑I 5939)1Df3Q1 I this report 71 O I Period g Beginning tf Endingcomputer printed 2
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<br /> ,I t MONTHLY AVERAGE 9 le > .5- Mea. - 4 3 � v
<br /> j MONTHLY HIGH L1 7
<br /> MONTHLY LOW 3 �., j U c7o G (a
<br /> TOTAL RECORDINGS/MO. a,
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<br /> Times Exceeded
<br /> REQUIREMENT #2 �
<br /> p Times Exceeded t
<br /> REQUIREMENT #3 r
<br /> t Times Exceeded
<br /> . . iEnter number of Samples Typed Name of Pnnc pal Executive Officer
<br /> taken during the. day. .SCO arrell I declare under penalty of perjury that the foregoing is true and accurate, and that
<br /> the sampling procedure and analysis used for the column constituents was as s I "
<br /> Farm 01.9/74 Last First MI fled. in the Waste Discharge Order.for this facility sig nerd re of P:nupol Executive Yr. Mo. Day. COPY
<br /> 01f cer or Authorized Agent Date
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