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Ir <br /> 1684 ROGERS AVEtrUr= WELLUE" J!'ISP {'CTION CDEC.� � �� <br /> BLAINE SAiIJOSE,CALIFORNIA 85112 CJS L <br /> FECt! SEIqViCES (106)573-717`1 FAX <br /> (4001570-0555 Pr-OtIE 1 t, Ct1Bnt <br /> Site Address—Mgg <br /> r z <br /> LO OCT 16 PH 1. 24 <br /> Technician 74 <br /> r O <br /> Date <br /> tiv bol- <br /> [LJdd <br /> on box? 6 Casino secure, 12 Water standing rn tivellbox7 15 'Keit cap funchvnaf7 <br /> rolcsn i f Lasmo cut levet� 12a_StMding above the top of easing? i6 Can cap be pulled loose? <br /> lts nnssrng7 8 f7ebrrs in weflbox% 12b 5ta-idIng below the top of casrnq; 17 Can cap seal otit water%lts stripped' 9 'Neffbox is teo far above prade7 12c Watereven with the topof casain' 19 Padlock present? <br /> at trrtact" 10 Wellbox is too Far [pfmr grade 13 Well E--p present- fl? Padlock fumbonaf7 <br /> 11 Wellbox is crushed/damaoed'% 14 Werl cap 10und secure? <br /> 0 Check box if no deficiencies were found Note below deficfencleS you were able to correct <br /> Wefl I D Deficiency Corrective Action Taken <br /> Ilole below off deheticres tflai could not be corrected and still meed Io be corrected <br /> BTS Office assrons or !_late Date <br /> Well I U f-'er5151ir1a Defic)ency defers Correctron to <br /> assrorleLi corrected <br />