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r c <br /> TRIANGLE ENVIRONMENTAL, INC. <br /> SPILL BOX ANNUAL INSPECTION REPORT FORM, <br /> I. FACILITY INFORMATION <br /> Facility Name: UV)Itc --fDate of Testing: <br /> Facility Address: gjjo IM��rL <br /> Facility Contact: w� f- <br /> Phone- R <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) FjII/Vapor Time Time Or Visual P/F <br /> 101A iy��Comments: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the factscsttated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:-P- -(_ &�,4A / Date: 1a-Q�A-C <br />