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Waste Tire Vvey & Inspection ReertsuRVEY REQUIRER <br /> °--- State of California � <br /> CIWIVIB Integrated <br /> (Ne04104) Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> PartC - Facilit Information BLUE OR BLACK INK PEN <br /> TPID- =- Inspection j -- r - - ---- — <br /> Site Suffix: �l �� P•, _ ��i ! Report <br /> Number: <br /> SWIS mInspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken Q Yes Q No <br /> Property OWnerl .; <br />