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INSTRUCTIC , FOR DISCHARGER CALIFORNIA STATE WATER RESOURCES CONTRA BOARD
<br /> ,. Remove COPY 4 (dark yellow) and use for yearDISCHARGER SELF MONITORING REPORT
<br /> j, 2. Use ballpoint pen or typewriter for data entry onn forms.
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<br /> 3. Provide dates for beginning and ending in reporting period blocks. az TRACYr n CITY F
<br /> 4. Provide data as specified under column headings. CALIFORNIA RECIONAL. WATER QUALITY TRACY STP
<br /> 5. Enter monthly summary data (MONTHLY AVERAGE, MONTHLY HIGH, etc.). C2,4TROL BOARD
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<br /> b. Appropriate signature is required at the bottom of the form. - r
<br /> 7. Remove COPY 3 and retain for your records. CENTRAL VALLEY REGI7Nf PD f3E)X 1329
<br /> 8. Send COPY IXAQX*VbXX,)$*CF KOXo48LK( , X oXXXX 3201 S STREET i„", TRACY CALIF
<br /> SACRAMENTDv CA 95Sl.6 <$ 95376
<br /> YOUR REPORTING PERIOD IS ?-ONTI-ILY AND YOUR REPORTS MUST s<
<br /> BE SUBMITTED BY F7DAYS FOLLOWING THIS PERIOD.. State NPDES Permit PAGE
<br /> Year Mo. Day Year Mo. Day Code Number Year Mo. Day
<br /> Transaction Facility a a Year/Month for Reporting Date form was
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<br /> + MONTHLY AVERAGE
<br /> MONTHLY HIGH
<br /> MONTHLY LOW
<br /> TOTAL RECORDINGS/MO.
<br /> REQUIREMENT #f
<br /> Times Exceeded
<br /> REQUIREMENT #2
<br /> Times Exceeded
<br /> REQUIREMENT
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<br /> *Enter number of samples Typed Name of Principal Executive Officer I declare under penalty of perjury that the foregoing is true and accurate, and that � /ly I
<br /> taken during the day. the sampling procedure and analysis used for the column constituents was as speci- L II
<br /> Form Q2-9 74 Last First MI Pied in the Waste Discharge Order for this facility. gnacre of P than Executive vr. Mo. Day COPY j
<br /> / matu r or Authorized Agent Date
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