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City/County <br /> Wastelre Survey and Inspection Repol Mailing Address <br /> bUN: <br /> Phone Number <br /> ;tate of California <br /> :IWMB-54(10103) <br /> SART D -Notes Page?of 2- <br /> File Number: Inspection Date: l l� ZI) <br /> Bush* ss/Facility Name: GPS Coordinates: <br /> J <br /> lA�D a6 <br /> G16- <br /> 6 ✓ <br /> 4 <br /> Follow-up: <br /> ❑ Letter 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 Signat re Phone: .2:D(�7 761 <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />