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` City/County <br /> Waste ire Survey and Inspection Re Mailing Address <br /> Phone Number <br /> tate of Califomia �o� 'C® ycnn rpryv�?�vV1 a� �� <br /> IWMB-54(10/03) I // ��"�((JJJ <br /> Page�of� <br /> 'ART D-Notes <br /> Inspection ate: <br /> File Number: <br /> Z <br /> B inessl Facili Name: GPS Co rdinat <br /> I <br /> o* <br /> Follow-up: <br /> ❑ Letter of violation ❑ Violation re-inspection E] Refer to CIW MB 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 Sign re Phone:llm <br /> it_ Copy:CjVVB Yellow Copy: Operator Blue Copy: LEA <br />