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o <br /> City/County <br /> Waste Tire Survey and Inspection Repo Mailing Address <br /> Number <br /> tate of Califomia <br /> IWMB-54(10103) _1 <br /> C � PagW2--of,_ <br /> 'ART D-Notes Inspectio a : <br /> File Number: <br /> GPS or inates: <br /> Busin sI F cility NBM—e: �- <br /> B( N O �\LYS ✓ 6�AC� I �i� �r�� .►9AV <br /> I <br /> i <br /> Follow-up: RefertoCIWMB Date: <br /> ❑ Letter of Violation ❑ Violation re-inspection ❑ <br /> Date Mailed: Date: <br /> ❑ Other Referrals <br /> ❑ If this box checked NFA required. ❑ No tires, remove. ❑ Out of business, remove. <br /> Phone:;6-9Inspector's Sign e <br /> r Blue Copy: LEA <br /> B Yellow Copy: Operato <br />