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City/County <br /> Waste Tire Survey and Inspection Rep Mailing Address <br /> i3Phone Number <br /> tate-of Califomia `�� - ✓1.V 1 1 <br /> IWMB-54(10/03) � 1� <br /> �/V Page�of�- <br /> 'ART D-Notes <br /> File Number: Inspection Dat . <br /> Busin ss/F cility Name: GPS Coor nates: <br /> kl-711r <br /> - <br /> or� <br /> i <br /> Follow-up: <br /> ❑ Letter 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 Signature Phone: <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />