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WELLHEAD INSPECTION CHECKLIST Face of <br /> Client Date -LTj 0 LA, <br /> Site Address K-. . V1 olio meq,e S S kQ t,(C.�o%A, <br /> Job Number 0k69yL%-(ZA%A-1-) Technician r,%- i,ty�'C`7dLoa,-, <br /> Well Inspected- Water bailed Welilaox Other Action Well Not <br /> Well <br /> Corrective From Components Cap Lodi Taken Inspected Repair Omer <br /> Action Required Weobox Cleaned Replaced Replaced (explain (explain Submitted <br /> Well ID below) below <br /> — � X, <br /> (Aw-z x <br /> rAw-� <br /> NOTES <br /> BLAINE TECH sERVICES WC SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO wms bWnetech-com <br />