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WELLHEAD INSPECTION CHECKLIST Page 4- 1 <br /> Client t t1 _�. Date -- 7r 1-03 <br /> Site Address _arZ',LC.V, <br /> Jab Number _p3rt_�Zt- S-Z Technician <br /> Well Inspected- Water Belted Wellbox Other Action Well Not <br /> No correcWe Frorn Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Wellbox Cleaned Replaced Replaced (explain (explain subrrrltted <br /> below) below <br /> ■ _O y(a <br /> M !� <br /> ^ a <br /> vw <br /> V�4 <br /> e <br /> NOTES: _ � � - c1 L' oe-kc-C <br /> SLANE TECH SERVICES M SM4 JOSE SACRAMEMTo Los ANGELES sari nrEr.,o ww+r nlav�4lud�corn <br />