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' 1880ROGERSAVENUE WELLHEAD IrSPEC 100 rrFjECKLj 1 ' <br /> BLAINE <br /> TECH SERVICES A� SAM JOSE,CALIFORNIA 95112 Client EXXON 7-0137 O <br /> (408)573-7771 FAX <br /> T ry�b (409)573-0555 PHONE 1605 SOUTH EL DORAD <br /> Site Addres- STOCKTON <br /> ' Technician `!\ <br /> Date f 3 1/-62C) <br /> ' f Lid on box? 5 Casing secure? 12 Water standing in wellbox? Is Well ca functional? <br /> 2 Lid broken? 7 Casing cutlevel7 f2a Standing above the top of castng7 16 Can cap be pulled toose7 <br /> ' 3 Lid bolts missing? 8 Debns in welfbox7 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seat intact? 10 Weflbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Weflbox is cnrshed1damaged7 14 Well cap found secure? <br /> Eff""Check box If nb deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all deftencres that could riot be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> ' Well I D Persisting Delici oncy defers Correction to assigned corrected <br /> r <br /> I <br />