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4City/County <br /> Waste 1 ire Survey and Inspection Rep rt Mailing Address <br /> Phone Number <br /> tate of Califomia <br /> I W MB-54(10/03) �c`h J 6 '(- / tN✓�'A� L�� <br /> ` c. Page D--of Z <br /> ART D-Notes ''�o Inspectio Date: <br /> File Number: � U <br /> B siness/Fa ' i Name: ` GPS oordin es: <br /> 1 lie. his"`' <br /> I <br /> Follow-up: <br /> E] Letter of violation 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 Sign Phone: <br /> e Copy:CIWMB Yellow Copy: Operator Blue Copy: LEA <br />