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WELLHEAD INSPECTION CHECKLIST Page ( of <br /> Client r W Date �1L10 <br /> Site Address S f-0 CIA Fe h <br /> Job Number 0G011"7-6/1 1 Technician Agie f <br /> Well Inspected- Water Salted Wellbox other Acton Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Wel! ID Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> Lr- <br /> i <br /> I <br /> NOTES <br /> BLAINE TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO wwwblamelech Com <br />