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WELLHEAD INSPECTION CHECKLIST PageOfOf�_ <br /> Date u L4 Client t^J r:a, L%,t Coot,Z,-v w wtt �•. <br /> Site Address kA LA 14 1 <br /> Job Number t9 a d;k.-7- - OAk L Technician d.l .►l���r�c.�c�-�. ___ <br /> Debris Other Action Well Not <br /> Well Inspected- Water Bailed Wellbox Cap Removed Lock Taken Inspected <br /> No Corrective From Components Replaced From Replaced (explain (explain <br /> Well ID Action Required Wellbox Cleaned Wellbox below) below <br /> X <br /> KQ-3 <br /> NOTES: �J'?i <br /> BLAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO www.blainetach.corn <br />