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City/County <br /> Waste Tire Survey and Inspection Re t Mailing Address <br /> L:::: Phone Number <br /> tate of Califomia <br /> IWMB-54(10/03) <br /> Page of o <br /> 'ART D-Notes <br /> File Number: Inspection D e: <br /> g O Lf <br /> Business/ Facilit�ame: GPS Coo dinat <br /> i <br /> Follow-up: <br /> E] Letter of Violation Violation re-inspection E] 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: 7�5 <br /> Ite Copy: CIWMB Yellow Copy Operator Blue Copy: LEA <br />