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� City/County <br /> Waste Tire Survey and Inspection Repo Mailing Address <br /> L:::: �^ Phone Number <br /> tate of California <br /> IWMB-54(10/03) 2_O� �1 2 <br /> Paged-of <br /> 'ART D-Notes Inspectiop Date: <br /> File Number: A <br /> Business)Facility N e: <br /> GPS C ordin es: <br /> e <br /> \\ aCi\I-A+ <br /> pFollow-up: Refer to CIWMB Date: <br /> etter of Violation ❑ Violation re-inspection ❑ate Mailed: Date: <br /> ❑ Other Referrals <br /> ❑ If this box checked NFA required. ❑ No tires, remove. ❑ Out of business, remove. <br /> --� Phone: <br /> Inspector's Signature <br /> - hite Copy: CIWMB Yellow Copy: Operator Blue Copy: LEA <br />