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Waste Tire vey & Inspection Rc r SURVEY REQUIRED <br /> ka <br /> State of California <br /> CIWMB 783 (New 04/04) <br /> Comments Form -- - --- <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - <br /> Site f - Inspection _ _ <br /> t !� Report ,X ® .1 1 © J <br /> Site Suffix: V Number: <br /> Inspection Number on the associated Survey form(Page 1) <br /> Comments <br /> tX&l n I C4.1 <br /> -�!'8J 0 'OHOd <br /> &-c ot-1�- <br /> 11 I'D � -Ib <br /> i <br /> l � <br /> Ie XIA MIDI LIQ 1 2 3 42408 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />