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WELLHEAD INSPECTION CHECKLIST Page Z of. 2. <br /> Client Date <br /> Site Address --- <br /> Job Number WZA kt. --6c,t _ „ . Technician p,�(h.r�•�,. <br /> Well Inspected- Water Balled Weflbox Other Action Well Not <br /> No Corrective From Components Cap lock Taken Inspected Repair Order <br /> Well ID Action Required .Welibox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> W-Q <br /> VW-lb <br /> vw -t( � X <br /> v w-iti X <br /> 2,p YC <br /> MC <br /> 0-3� <br /> NOTES: <br /> BLAINE TECH SERVICES.INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO www.biaimelech.cwm <br />