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... ..... <br /> ----------------- - ---- --- .......... <br /> W . . <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> cl <br /> CalRecye 181 11 - 1177743 <br /> Dept.of Resources Recycling and RecRovery(CalRecycle) Survey Form Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 5 C1 0 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C�a V-k If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> & <br /> Physical Address uJ-4 <br /> 7701 ekf 1-.,, <br /> Inspection Date '5 <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> / 0 : 0 0 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(; <br />