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J i <br /> i <br /> BLAINS 1680 ROGERS AVENUE WELLHEAD <br /> SANJOSE CALIFORNIA 95112 INSPECTION CHECKLIST � <br /> TECH SERVICER.4 <br />• (408)573-7771 FAX Client <br /> OJT M&Z) (408)573 0555 PHONE <br /> o� A Site Address Ute-' +e H 0.0 <br /> Technician Q <br /> Date [� <br /> 1 Lid on box? 6 Casing secure 7 12- Water standna in wegbox? 15 Well cap functional' <br /> 2 Lid brolten7 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid baits missina7 8 Debris in weffbox7 12b Standing belox the top of casing? 17 Can cap seal out wetgr 7 <br /> 4 Lid bolts stripped' 9 Welfbox is too far above grade? 12c Water even with the top of casrng7 18 Padlock present? <br /> 5 Lid seal intact? 10 Welibox is too far below grade? 13 Well cap present7 19 f adfodc funchorta17 <br /> I 1 Wellbox is crushedldarnaged? 14 Well cap found secure <br /> Check box if no deficiencies were found Note below deficiencies you Were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all defiencles Ilial could not be corrected and still need to be corrected <br /> B TS Office assigns or Date Bale <br /> Well I D Persisting Deficiency defers Correction to ass.oned corrected <br />