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---. <br /> Waste Tire S@ey & Inspection Rep SURVEY REQUIRED <br /> •••'�• State of California --- - <br /> ------ Comments Form --- <br /> � CIWMB 183 (New 04/04) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> © 1 I _ ` Z 1 <br /> TPID- tion <br /> � -3 � � � � Report Report 3 2 <br /> Site Suffix: Number: <br /> Inspection Number on the associated Survey form(Page 1) <br /> Comments <br /> �h -\ OC, <br /> i <br /> or. To N3 llzvt, 2 ,cow. <br /> ON7 '� <br /> AK <br /> 422 ,j <br /> ( I <br /> 42408 <br /> E; XA M PL. Ei : � .� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />