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® Waste Tire S,_. vey & Inspection Repm. Inspection Report Number <br /> CalRee�(cle State of California <br /> J CalRecycle181(Rev.10110) Survey Form Page 1 11 - 1226515 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` r ( d q 1 1 O I Inspection Type(Fill one) <br /> Site Suffix: I 10 ` 1 1 I * Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 5 QTY) JD`"V I Ltd n CU1,(,d1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ti <br />