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® Waste Tire SeveY Inspection& ItiRe Mt <br /> SURVEY REQUIRED <br /> W <br /> "•'�' State of California <br /> W <br /> CIWMB183 (New 04104) Comments Form <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 0 Inspection _ <br /> Site Suffix: �j - O Report I I p �y <br /> I Z- � � / Number: C q-3 <br /> Inspection Number on the associated Survey form(Page 1) <br /> Comments <br /> �- J< <br /> io <br /> JE <br /> - -- - AMP 42408 <br /> E� 112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />