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city! county <br /> Waste 1 ire Survey and Inspection Rep . � Mailing Address <br /> Phone Number <br /> :e of Califomia <br /> JMB-54(10/03) <br /> Page Zof 7,,.RT D -Notes Inspect.on D te: <br /> ?e Num'-er: <br /> GPSCoo- inates: <br /> ,usinessl Facility Name: <br /> i <br /> fi <br /> A <br /> � V ' <br /> a <br /> I <br /> I <br /> Follow-up: Refer to CIWMB Date: <br /> ❑ Letter of Violation ❑ Violation re-inspection ❑ <br /> Date Mailed: Date: <br /> ❑ Other Referrals <br /> F1 If tires, remove. E] Out of business, remove. <br /> If this box checked NFA required. ❑ <br /> Inspector's Signature <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />