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WELLHEAD INSPECTION CHECKLIST page J of <br /> Client Uri - Date o2'16..of <br /> Site Address Z N <br /> Job Number Q ' X�f _ Tet;hnician K � <br /> Well Inspected- Water Balled Weubox Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Weilbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> w-rq <br /> s y <br /> NOTES <br /> BLAINE TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN o1EGO www btaxteteM com <br />