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�1 <br /> • WELLHEAD INSPECTION CHECKLIST page `Of <br /> Client Date 3 Z <br /> Site Address Z 3-7S� LJ- G re, ,t-N< 1�D, Tc t <br /> Job Number t�,, '��3zS�� �S - Technician "-' T,-7.,>, S KK*,%clvx <br /> Well Inspected- Water Bailed Wellbox Ther Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected RepairOrder <br /> Well ID Action Required Wellbox Gleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> MCA.)' � x <br /> NOTES4,,,, Sj ,= 1,01c h 4S i.,. M w <br /> BLAINE TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN OIEGO www blamtechcom <br />