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City/County <br /> Waste ire Survey and Inspection Ret Mailing Address <br /> i:::: �`�� Phone Number <br /> tate of California <br /> IWMB-54(10/03) / 1 �' �A,Z <br /> 'ART D -Notes _ Page <br /> File Number: Inspection Date: <br /> Business/Facility ame: GPS Coordinates: <br /> /0, <br /> <57 <br /> 1-4 <br /> Follow-up: <br /> ❑ Letter of Violation F1 Violation re-inspection E] 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 Sign a Phone: �� / 7� 0 <br /> -hiYeCoPY: CIWMB Yellow Copy: Operator Blue Copy: LEA <br /> I <br />