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City/County <br /> Waste 'fire Survey and Inspection Rep t Mailing Address <br /> ����_ Phone Number <br /> tate of Califomia ��► "a �jt � �" <br /> IWMB-54(10/03) 3ae-1 <br /> Page=of 2 <br /> 'ARTD-Notes L <br /> ection te: <br /> File Number: 2 <br /> Business/Facility Name: GPS C rdina s: <br /> 17 �. <br /> 141A -o <br /> - a <br /> Follow-up: <br /> ❑ Letter of Volation ❑ 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 ure <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />