Engine Information: Engine Make: Engine Model: Engine Date of Year: Manufacture: Engine Serial Number or Air District ID Number: Engine Horsepower: Engine operational? Fuel used? Engine Family Number: Yes No Diesel Other: For Pre-Dismantler Inspection ONLY, Specify Dismantler: Contact Name: Phone: Engine operational? Yes No For Dismantler Inspection ONLY, Specify Dismantler: Contact Name: Frame Rails Cut? Engine Destroyed? Yes No Yes No Comments: I certify under penalty of perjury that: 1) the information provided above is accurate, 2) the pictures are of the inspected equipment, 3) the pictures clearly depict the inspected equipment, and 4) that I understand that this inspection form is incorporated in the agreement with the <air district>. Signature: Date: Authorized Name: Air District / Dealership: Address: City, State, Zip: Phone Number:
Engine Information: Engine Make: Engine Model: Engine Year: Date of Manufacture: Engine Serial Number or Air District ID Number: Engine Horsepower: Engine operational? Yes No Fuel used? Diesel Other: Engine Family Number: For Pre-Dismantler Inspection ONLY, Specify Dismantler: Contact Name: Phone: Engine operational? Yes No For Dismantler Inspection ONLY, Specify Dismantler: Contact Name: Frame Rails Cut? Yes No Engine Destroyed? Yes No Comments: I certify under penalty of perjury that: 1) the information provided above is accurate, 2) the pictures are of the inspected equipment, 3) the pictures clearly depict the inspected equipment, and 4) that I understand that this inspection form is incorporated in the agreement with the <air district>. Signature: Date: Authorized Name: Air District / Dealership: Address: City, State, Zip: Phone Number:
april2017_boarditem_proposedmoyerguidelines_vol2_v2_tracked_changes.docx