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-� <br /> sp <br /> City/County <br /> ._ Waste Tire Survey and Inspection Report Mailing Address <br /> to of California Phone Number <br /> JMB-54(10/03) i <br /> SRT D -Notes (_ Page �of <br /> He Number: Inspection Date: <br /> �usiness/FaciliWNNe: _ GPS Coordinates: <br /> 7 r Tr <br /> /iii--� �/�-��� ��.-- �-«,��--i• <br /> ,-s /��ir►i/!7c rnt..✓)�rl'eS <br /> Follow-up: <br /> ❑ Letter of Violation ❑ Violation re-inspection ❑ Refer to CIW MB Date: <br /> Date Mailed: Date: <br /> ❑ Other Referrals <br /> ❑ If this box d NFA require . ❑ No tires, remove. ❑ Out of business, remove. <br /> Phone������J'� <br /> Inspector's Sig day <br /> hite Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br /> x IC�nti <br />