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WELLHEAD INSPECTION CHECKLIST Page <br /> Client FIFE i_ _ Date C�� <br /> Site Address -770:. Wi2EL-AlUv C-" ;joC,kraru <br /> Job Plumber D40113—TM r Technician !fit lt-(,4kCo v <br /> Well inspected- Water Bailed Wellbox other Action Well Not <br /> No Corrective From Components Cap loci, 1 aken Inspected Repair Carder <br /> Well ID Action Pequired Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below) <br /> Z J� <br /> [vim <br /> NOTES PAW -`( "` C-Ipbcttjo SFAL— 5ueuj�- pig-, 1Ncj � &,jg[fG <br /> btO fl EPA(IZ � D� <br /> i <br /> GLARIE TEMI SERVICES 1111, sA11}OSE 5 rPAM017O LOS—.tGEL6s SMI DIECO w �6Llnnl�rJlmnl <br />