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TRIANGLE ENVIRONMENTAL, INC. <br /> SPILL BOX ANNUAL INSPECTION REPORT FORM <br /> 1. FACILITY INFORMATION <br /> Facility Name: ` !'L Y �� Date of Testing: �-1'a >, <br /> Facility Address: `7 C M <br /> Facility Contact: Owner Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Ronnie Humphries <br /> Triangle Environmental, Inc. <br /> 2525 West Burbank Blvd. <br /> Burbank, California 91505 <br /> (818) 840-7020, (818) 840-6929 FAX . <br /> California Contractor License # 673971, A, C-10, HAZ, HIC <br /> 3. TEST RESULTS - DATA <br /> Test type <br /> Spill box/ Size Location Start End Hydrostatic Result <br /> Tank # Episode Product Box Mfr (gals) Fill/Vapor Time Time Or Visual P/F <br /> ops✓ L 10' V <br /> V o <br /> Comments: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To dee best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: QM, t �yyti� Date: <br />