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I <br /> �. TINGLE ENVIRONMENTAL, INC. <br /> SPILL BOX ANNUAL INSPECTION REPORT FORM <br /> 1. FACILITY INFORMATION <br /> Facility Name,: co Date of Testing: )a_' _ d <br /> Facility Address: s L <br /> Facility Contact: awhe�j` Phone: - <br /> Date Local Agency Was Notified of Testing: 1 a_)_ <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. a ) Fill/Vapor Time Time Or Visual P/F <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: \�V---< � � 4 / Date: <br /> 'V-Y <br />