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TRIANGLE ENVIRONMENTAL, INC. <br /> ,SPILL BOX ANNUAL INSPECTION REPORT FORM, <br /> 1. FACILITY INFORMATION <br /> Facility Name: Z Date of Testing: 9_a ,-.0L <br /> Facility Address: 11206 VtGe 11P 6ye <br /> Facility Contact: w Phone: CA� 2213 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector (if present during testing): <br /> � r vin <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) FillNapor Time Time Or Visual P/F <br /> 1 ® Fi Lt., 130 130 Vow <br /> Comments: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 9%nrrA _ Date: <br />