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Waste .,,re Survey and Inspection Re o► . city/county <br /> �'/ p P Mailing Address <br /> State of California �C-v '^�" ` ,r 7 Phone Number <br /> CIWMB-54(10/03) <br /> PART D -Notes Page —2--of 3' <br /> File Number: Inspection Date; <br /> ` 7 � <br /> Business/ Facility Name GPS Coordinates: <br /> da4-et-+ <br /> 12 <br /> Follow-up: <br /> ❑ 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 Signature Phone: 4L6�, ,?l� b <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />