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BLAINE <br /> ' A#{ E 1880 ROGERS AVENUE WELLIMAD ii.,4S ECTION CHECKLIST <br /> TECH S'cFtVlCcS.. SAM JOSE CALIFORNIA g5112 <br /> 1408}573-7771 FAX Client ' 78? <br /> (408)573-0555 PHONE <br /> Site Address--s,7&,%--- - ��-Bf..d• <br /> r 'r <br /> Technic:an ...L.� <br /> Data <br /> 7 pp�Y <br /> 1 lid on box? 6 Casing secure 7 12. Water srnaing in wellbox? 15 well c--n functional? <br /> 2 Ltd broken? 7 Casing cu(level? 12a-Standing above the too of Casing? 16 Can cad be pulled loose? <br /> 3 Lid bolts missirng7 9 Deans to welfliox 7 12b Standing below the tot)of casrnn7 17 Can cars seal out water <br /> 4 lid bolts strroped7 9 Wellbox is too far above?rave 7 12c Water even with the too of casino 7 18 Padlock present? <br /> 5 Lid seal intact'? 10 Wenlbox is too far below arade7 13 Well cav presenr7 19 Padlock functonal7 <br /> 1 i Wellbox is crushedldamaded7 14 Well coo forma secue7 <br /> Check box it no deficiencies were found Nate below deficiencies you were able to correct. <br /> 'Neil I D Deficiency Corrective Action Taken <br /> l <br /> I <br /> Nole below all detiencles that could not be correciea and stili need to be corrected <br /> BTS Office ass,ans or Date Date <br /> 'NMI I D Persislinta Deficiencl deters Correction to assioned corrected <br /> F�I c1ac�S <br /> f ! 7 -P> <br /> I <br />