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WELLHEAD INSPECTION CHECKLIST Page � of_�___ <br /> Date -Z`1-'63 - <br /> a Address L1\ ° cam+4\ 'SN-. <br /> Number Technician <br /> Well Inspected- Water Bailed Wellbox OtherAetlan Well <br /> No Corrective From Components Cap Lack Taken tnspe_ted Repair Order <br /> Nell ID ActionRequlred Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> ,Y\w <br /> OTES: <br /> 3LAME TECH SERV10ESrVC. GAN JOSE 5ACRAMEM'f0 LOS ANGELES SAN DIEGO www.hl2lnotech.coni <br />