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City/County <br /> Waste Tire Survey and Inspection Repo c Mailing Address <br /> L:::: Phone Number <br /> tate of Cal(10/ c�py� <br /> IW <br /> MB-54(10/033) 7/ 7A '2m <br /> 'ART D -Notes S Pagef�— <br /> File Number: Inspection ate• <br /> 2 � <br /> Bu iness/Facility Name: GPSates: <br /> o <br /> 9C v y <br /> Follow-up: <br /> E] Letter of Violation E] 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 /> 910 <br /> Inspector's S <br /> i nat Phone: <br /> g <br /> W e opy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />