That is just a bit of php code less the firewall test at the bottom of the page.
Here is the page source code. Be sure to use the .php extension on the page.
Code:
<html>
<head>
<title>Info Page</title>
</head>
<body bgcolor="#ffffff">
<div align="center">
Below you will find your requested information.<br>
<br>
<?php print "Your ip is: $REMOTE_ADDR <br><br>
Your browser is: $HTTP_USER_AGENT <br><br>
The URL that you came from is: $HTTP_REFERER" ?><br>
<br>
<br>
Today's date is<br>
<?php echo date("Y-m-d"); ?><br>
<br>
<br>
</div>
</body>
</html>