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' t <br /> City/County <br /> .. Waste Tire Survey and Inspection Report Mailing Address <br /> Phone Number <br /> :e of Califomia <br /> /MB-54(10/03) <br /> .RT D -Notes Page gof <br /> ile Number: Inspection Date: <br /> usiness/Facility Name: / GPS Coordinates: <br /> Z22 <br /> T,�.I,o io 3 Sis O/ <br /> =ollow-up: <br /> El 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 /> Inspector's Signtura <br /> Phorle.'�07 )y�o��3ySS <br /> White Copy: WMB Yellow gop Opera or Blue Copy:LEA <br /> �cPi�cE A ._ 1_/ <br />