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Survey and Inspection Re City/county <br /> %* <br /> Waste Tire Sur y p P Mailing Address <br /> Phone Number <br /> tate of Califomia � <br /> IWMB-54(10/03) <br /> 'ART D -Notes Page -,f <br /> File Number: Inspecti Date: <br /> 1 <br /> Business/Facility Name: GPS oordin es: <br /> 52Nt _ <br /> Follow-up: <br /> F1Letter of violation F1 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 Signatur - Phone:1&2 �73. 7a� <br /> C CIWMB Yellow Copy: Operator Blue Copy: LEA <br />