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Waste •e Survey and Inspection Repo, city/county. <br /> Mailin;Address <br /> State of California `'�'� "' Y` �'` '' ��' ��''`�"`zi'r�� i 7�' �7� Phone Number <br /> CIWMB-54(10/03) <br /> PART D - Notes Page Z�of 2 <br /> File Number: Inspection Date: <br /> Business/ <br /> /FFacility Name: / I GPS Coordinates: <br /> (/�1J4111— <br /> c' <br /> 14 <br /> CAw �l <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 /> 1 <br /> Inspector's Signature Phone: 2-01) <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />