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Waste Tire S&,V <br /> ey & Inspection Rer SURVEY REQUIRED <br /> State of California <br /> CIWMI3183 (New 04104) ments Form <br /> California Integrated Waste Management Board BLUE OR BLACK INK P E N <br /> Business Profile _ Inspection Details <br /> TPID- Inspection <br /> Site Suffix: S� $ / Z Report I — �/ �1 S- L <br /> Number: <br /> Inspection Number on the associated Survey form(Page 1) <br /> Comments <br /> CX O&W r o f <br /> �MEI 42408 <br /> � X � h�, P (r � 111273 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA P—A� <br />