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1680 ROGEAS AVEr1UE tiVELLUE" (INSPECTION CHECKLISry <br /> BLAINE SA14 JOSE,CALIFORNIA 95112 <br /> TECH SERVICES.. 140ef 573-7T7i FAX <br /> (400)573-0555 PHONE Client���(Jt V� - <br /> =�4� J Slee Address <br /> Z Technician <br /> Date <br /> 1.Lid on bvx? 6. Casing secure? 12__YVater-slanding.1n,wellbox? 15:Welt cap'ltrnctiorial7 <br /> 2.Ud brofcen7 <br /> 7- Casing cut levet? 12a Standing above the IDP of casing? 16.Can cap be puffed loose? T <br /> 3. Lid bolts missing? 8. Debris in weilbox? 12b.Standing below tte top of casing?n9� 17.Can cap seat out water? <br /> 4. Lid bolts stripped? 9. Wellbox is too far above grade? 12c_Water even with the top of casing? 18. Padlock present") <br /> 5_ Lid seal intact? 10. Wellbox is too far below grade? 13. Well cap present? 19. Padlock functiorrai7 <br /> 11.Wellbox is cushedidamaged7 14_ Well cap found secure? <br /> 0 Check box if no deficiencies were found_ Note below deficiencies you were able to correct. <br /> Well I-D. DeficiencyCorrective Action Taken <br /> 0 <br /> Nole below all deliencies that could not be corrected and still need to be corrected. <br /> STS Office assigns or Dale Dale <br /> Well I.D. Persisting Deficient defers Correction to. assi n corrected <br /> f1� 'n Ido WI � <br /> t✓� <br />