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' WELLHEAD INSPECTION CHECKLIST <br /> Page t of <br /> Client FF d- FfU+•7� Date y 14 45- <br /> Site Address r��,v► �l/ W510 le-/►-. <br /> ' Job Number Technician PCt4rccL- <br /> Well Inspected- Water Bailed Wellbox Other Aclion Well Not <br /> ' No Corrective From Components Cap Lock Taken Inspected Repair order <br /> Well ID Actlon Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> r <br /> NOTES <br /> y <br /> ' BLAINE TECH SERVICES INC SAN.105E SACRAMENTO LOS ANGELES SAN DIEGO wwwblainefech com <br />