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OCT -16. 48 (Pltl) 15 20 BLAINE TECH SERVICES, INC TEL 408 573 7771 P 001 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Wr���,� , Site# Inspection date Th l/fs <br /> Site address�`1, ._ Il '" � Inspected by <br /> r44 `A 1 BTS Event# C Zi- �-- <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above well top? a Can trap seal out water? <br /> 3 Lid secure? 5b. Standing below well top? 9 Padloqk present) <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> EPI/C'heck box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well I.D. Doflclency Corrective Action 'taken <br /> 0 <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS Office aspigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correctlon to: assigned corrected <br /> Post-it"Fax Note 7671 Dora <br /> r l° <br /> To Pagap► <br /> ^,, a <br /> �ro <br /> r wv rt� <br /> Co/Depr V, S. .rt co <br /> Phones �-t W Gt'`'v`�J <br /> Phorre Y <br /> Fax PFad,4 <br /> '3Z s,' <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />