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City/County <br /> ... Waste ire Survey and Inspection Repo, tMailing Address <br /> State of California Phone Number <br /> CIWMB-54(10/03) <br /> PART D - Notes Page of <br /> File Number: Inspection Date: <br /> Business/ Facility Name: GPS Coordinates. <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 /> 2c <br /> Inspector's Signature ),O `L a_ Phone: II <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />