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VVtzLLt1i INSPECTION CHECKLIST AND .:PAIR ORDER T <br /> C . C4Llnspectlon Date ~CJ Z <br /> Site Address C? r t r Lo .+ inspected By <br /> d on box? 6 Casing secure? 12. Wafer standing in Wellbox? <br /> 2 Lfd brakes? 15 Well cap functional? <br /> 7. Casing cut levet? 12a Standing above the top of casing? 16 Can cap be pelted Inose? <br /> 3 Lid bolts missing? B. Debris in welibox? 12b.Standing below the lop of casing? 17 Can cap seal out water? <br /> 4 Ud 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? <br /> 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14. Well cap found secure? <br /> ,Fz� Check box If no deficiencies were found Note below cl clencles you were able to correct. <br /> Well l D. eficiency Corrective Action Taken <br /> Note below all deffencfes that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well ! D. Persistin Deficienc defers Correction to- assigned corrected <br />