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tl 1680 ROGERS AVENUE xyyNSPECr1110N CH{'_K--ASTBLAfNE <br /> TECH SERVICES.s SANJOSE CALIFORNM 951112 <br /> w . (408)573-7771 FAX Client c� t+�•U .,� <br /> (408)573 0555 PHONE <br /> aw4w` Site Address _ E 3 <br /> ? �1 <br /> Technician <br /> r <br /> 'I r Date <br /> 1 Lid on boxy 16 Casing secures 112 Water standing in welibox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a.Standing above the top of casing? 16 Can cap be pulled lvase7 <br /> 3 Lid bolts missina7 8 Debns in wellbox7 12b Standing below the top of casing? 17 Can can seal out water'? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casino? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functronall <br /> 11 Wellbox is ayshed/darnaged? 14 Well cap found secure? <br /> ICheck box If no deficiencies were found Note below deficiencies you were able to correct <br /> I <br /> Well I D -Deficiency Corrective Action Taken <br /> I <br /> I <br /> I <br /> • <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Dale <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br />