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• f � <br /> WELLHEAD INSPECTION CHECKLIST � <br /> Page A—of <br /> client c t Dale <br /> Sile Address / 2- 4o-) g A —_ <br /> .lob Number g�2���"Z�,-V►/1_5�Z Technician �G <br /> Well Inspected- Water 6aded Wellbox I Other ACUDn Well Not <br /> No correctrVe From Components Gap Lock Taken Inspected Repair Order <br /> Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> Well ID beLEEI below, <br /> ^ � <br /> s-3 <br /> Sr <br /> 4 <br /> DOTES <br /> eLA1ME rwi senvices we SAN JOSE SACPAMF---HrO LOS ANGELES Sm i Mrp vr+w{��au�glCU�tuR� <br />