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OFFICE OF SlltF'ACE P4.NING RECI11MtiTIC{J AND ENFCRCENENP <br />RANDCtd SAMPLE HEIR SUPPLEMSIf <br />1. Permittee / ~~A C~i7- 5. Days since Cast State Cortplete Inspection (LSCI) 1{~ <br />/~ <br />2. Permit Nurttxr __ `~ _ ~~ - ~f7 ~JC+~~~ff~%l-2 ~ ~~ f 6. Block 25 Categories in NON-CUt"PLIANCE this R5I lZ <br />3. Joint Inspection I~I Y/tJ 4. Date L-"? FF 9~ 7, Total Violations this RSI G <br />{t*f#*#R4***t*##****##*#*#t*#*##*#****t##**##****#f*;#*#*******#****#*#****##*t**#*t**t*********it#tt *ttif*#t***R**RR*# <br />d. List (only once) all violations: <br />1) tl'iere State enforcement was required and taken during the LSCI; <br />2) recorded in the LSCI report tut the State failed to take enforcement; <br />3) observed dlring this RSI ~hidti clearly existed dining the LSCI tut the State failed to take enforcement; and <br />4) existing dlring this RSI ~ttich are not already listed under one of the categories above. <br />A B C D E F G H I J K <br />SPtxIFIC STA1E BIIS7C 25 ABA'hA S[AIE RFAICN IF SQtIO.Rd~55 CIAPE <br />IAN/BB7.uCrIC!! VIQ[A1ID CA3FACAY (Y/N) AC1ZQ7 lNCI1ID CAIbE PEA IhPACT AC'rIQ1 OPTICY~IAI. <br />1._~~~~~ <br />-_---~----- I I I I I I I~ II <br />2._J~JJ- I_I I_I I_I I I I I G <br />I I I 1 I I <br />3.~_JJJ- I_I I_I I_I <br />I I I I I i 1 <br />I_I I_I I_I I_I <br />-.. I I I 1 1 I 1 _.. I I 1 I I I I 1 I I I I i <br />•,_/~_JJ_ I_I I_I I I_I I_I I_I I_I I_I I_I I_I <br />D{i¢lptlml <br />I 1 I I I I I I 1 I 1 I I I I I I I I I <br />S.~J~_J- I_I I_I I_I I_I I_I I_I 1_I I_I I_I I_I <br />6 <br />I I <br />7._J~_l~_ I_I <br />I I <br />I <br />_I <br />~~_~_._. <br />I I I I <br />I I I I I <br />I I I I <br />I I I I <br />y.J~J~- I_I 1_I I_I I_I 1_ I I_I I _I I_I I_I <br />DeaQlD~lml <br />I I 1 I <br />I I I I 1 <br />I I I I <br />I I I I I <br />10._J_J~_J_ I_I I_I I_I I_I I_ .I I_I I _I I_I I_I <br />DWClptlatl <br />( <br />i•SQ vlrto{.r..+. u )24#CL <br />ry. 1fi1M 1Rt~v~• b1 tp1 Ip( fRIMI N(IIiT„V <br />ll 5}lfttl m LC3, cltfd 111'151 m°"c`r^, YISH 112 ST{9L) . <br />11 I~ftalt Atct <br />11 U9ux1 WMfs Cmdltlau <br />~~ <br />11 Mar a lN1Ye]Y _ ~~In~ V w n 1a Wa <br /> <br />ll Hmf s M~ , <br />11 5}IfUd m 4901. rot elltl ll Ibt { vlolfLlm 11 Ynl[IClfl Mlvc 3) tlWY it Itb[fb <br />ll Clod vtls w L4Z, it Rslubd ey {uu Pollry 11 QRrftnc Ilfpl lgow ]1 Oowlt9d l) Cmflbtaelf <br />w <br />~i w•ea <br />M <br />" <br />{pfttent Ir<Gtnp SI LUf. IeCludfd uldr {Utz Vtogam ISI OUY[~ . <br />..n <br />G <br />M My -" <br />11 lYmtwd •Iroe 1611 11 LYm1q {!ti b llwt e({ Cl Ytlm 11 Mw s Mns <br />S) 9ftNt 6efR S) Vlol{tlm M. t~lltfll I11trd1 SI M3nu <br />f) RicL1w {llo~d INS f{¢01~d Pelt fl Cm{idrtfDlf <br />YI Sbo des b clM ~^" 1~~~`t°^"^"`~ <br />{I IRi#11V NN QsetT u (Sm~R YI Mme s ILLS <br />SI ous, el wac.u <br /> 91 ~~^•Idcfele <br />/+iM <br />11 a[f+'td to etfw Ktlm <br />it Y3Y1 Itaad <br />11 ilFm lawf <br />11 RfvlwulY Cl ted, <br />ebtte~mt 9#tdlm <br />e) AettW La4p or 4[on <br />C@VE in4*ctlm <br />61 '1[~L ltalyd <br />YI EN LaW [or <br />9finlt C*[Kt <br />