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• city/county <br /> Waste Tire Survey and Inspection Reot Mailing Address <br /> �-„�� 1,� � C�ea��, Phone Number <br /> tate of Califomia �� � ('�"' `y <br /> IWMB-54(10/03) <br /> 'ART D-Notes S� Page-z—of <br /> File Number: Inspectio Date: <br /> Ua <br /> Business/Facility Name: GPS ordin es: <br /> T' <br /> Follow-up: <br /> C] Letter of Violation E] Violation re-inspection ❑ 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 /> Inspector's Signatur Phone: <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />