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ELAINE 1680 FIOGERS AVENUE WELLREAD Ii-fSPEC ION C C�,��Z' <br /> TECH SERVICES.. SAM JOSE.CALIFORNIA 95112 <br /> (408)eT3-7771 FAX Client � <br /> MCA, (409)Cr`3-t756�I�I1C1ttE <br /> She Address 12 e. <br /> i <br /> Technician „z- <br /> Cate <br /> f=Liii'on'box7 67Casino-Secure! 12, Water standing in weilboxl 15c <br /> 2- Lid broken? i. Casing cut fe'!el? .Well wo fvncdanal? <br /> 12a.Stc'ndima above the tog Of Casir14^, 16. Can mp be pulled Nose? <br /> 3. Lid bolts missing? 8. Debris in wetlf ax7 12b.Standing befirm the iop Qf casing? 17.Can�sezi out Na <br /> 4. Lid bolts stripped? 9. Wellbox is too far above pude? 12c.Water even with the �r` <br /> tap of casing: 18.Padlock present? <br /> 5. Ud seal intact? 10.Wellbox is too tar below Grade? 13. Well C.o present? <br /> 11.Wellbox is aushedldameued? I 19. Padlock tvnc6onaf7 <br /> _ 14. We.f can found ser.,ire7 <br /> Check box if no deficiencies were found_ Note below deficiencies <br /> you were able to Correct- <br /> Well I.D. Deficiertcy Corrective Action Taken <br /> i <br /> I <br /> f <br /> Nole below all defiencies Mat could nol be corrected and still ne&d to be correYfed. <br /> BTS Office assigns or Dale Dale <br /> Well I.D. Persistino Deficiency defers Correction lo: <br /> assioned corrected <br /> II <br /> I <br /> I � i <br /> i <br />