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^ City/County <br /> and Ins ection Rep Mailin Address <br /> Waste"ire !Survey P g <br /> i 2 8 1M �kci_kK� <br /> one Number <br /> tate of Califo 0 fir,` , VIM h1 <br /> IWMB-54(10//03) <br /> 7 v <br /> 1,2 <br /> Page <br /> 'ART D -Notes File Number: Inspection Date: <br /> J � 6 <br /> Busi ss/Facility Nalne_ GPS Coordinates: <br /> 1VkW C, <br /> 411 <br /> i <br /> Follow-up: <br /> F1 Letter of violation E] Violation re-inspection E] Refer to CIWMB Date: <br /> Date Mailed: Date: <br /> ❑ Other Referrals <br /> ❑ If this box checked NFA required. ❑ No tires, remove. ❑ Out of business, remove. <br /> Phone: 3�����' <br /> Inspector's Sign <br /> tte MB Yellow Copy: Operator Blue Copy: LEA <br />