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Waste9re Survey and Inspection Repo► - <br /> City/County <br /> Mailing Address <br /> State of California `` �t"` j' � ( FnII� �r� ' Phone Number <br /> CIWMB-54(10/03) <br /> PART D - Notes Page-7--of v <br /> File Number: Inspection Date: J1124'>l <br /> L D <br /> Business/Facility Name* GPS Coordinates: <br /> 4— - ! 33t tet- — oo Z- <br /> � r <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 reouired. ❑ No tires, remove. ❑ Out of business, remove. <br /> Inspector's Signature / ZL4-� Phone: <br /> White Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />