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WELLHEAD INSPECTION CHECKLIST page t of t <br /> Client q Date ol 1z,tk - <br /> Site Address I ! 11s,� w y, & !C 6-"% <br /> Job Number Technician P at c <br /> Well Inspected- Water Bailed Wellbox Other Action Well Not <br /> NO Corrective From Components Cap lock Taken Inspected Repair Order <br /> Well ID Action Required Wellbox Cleaned Replaced Replaced (erplaln (explain Submitted <br /> below below <br /> • <br /> NOTES <br /> BLAWE TEOI I SERVICES UZ SAN JOSC 5ACRAf 1CNIO LOS ANGEUS SAN DICGO vnrx�Iamcmily cu�� <br />