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1 <br /> City/county <br /> Waste Tire Survey and Inspection Report Mailing Address <br /> tateof California e9 / x \`��� "��' Phone Number <br /> tat �.ti� f � \1�J <br /> IWMB-54(10/03) � �u�/ <br /> 1 Page of <br /> 'ART D-Notes <br /> File Number: Insp2- D e: <br /> a2 <br /> Business/Fatty Name: <br /> GPS oor nates: <br /> MQ- <br /> 1 <br /> C <br /> o --57 a <br /> FFo�llow-up: Refer to CIWMB Date: <br /> ❑ Violation re-inspection ❑Date: <br /> ❑ Other Referrals <br /> ❑ If this box checked NFA required. ❑ No tires, remove. ❑ Out of business, remove. <br /> Inspector's Signature <br /> Phone: �`? 5 5 3- 76 ?8 <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />