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4City/County <br /> L:::: Waste >< e Survey and Inspection Rep Mailing Address <br /> Phone Number <br /> tate of California <br /> IWMB-54(10/03) <br /> 'ART D -Notes � \ Page_ f <br /> File Number: Inspection Date: <br /> l 2� <br /> Buiness/Fa ili Name: GPS Coordinates: <br /> I <br /> Follow-up: <br /> ❑ Letter of Violation ❑ Violation re-inspection ❑ Refer to CIW MB 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 SignaturePhone: <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />