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13LBLAfNE 1580 ROGE; WENUE TMLLHEAD -XECTION CHECKLIST <br /> SERVICES SAN JOSE CALIFORNIA 95112 <br /> (408)573-7771 FAX ChentV29'— <br /> � � (408)573-0555 PHONE <br /> Q� Site Address 3 .rac.l l <br /> a° a <br /> • Technician % I1F3- _ <br /> Date .4—h/170 <br /> -'ND OC`V <br /> 1 Lid on box: 6 Casing secures 12 Water standing in welfbox? 15 Well cap functonal7 <br /> 2 Lid broken? 7 Casing cut lever 12m Standing above the top of casing? 16 Can cap be pulled loose? <br /> 5 Lid bolts missing 7 a Debris to wellbox? 12b Standing below the top of casing 7 17 Can cap seal out water? <br /> 4 Ltd bolts stripped? 9 Wellbox is too far above grade? 12c water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 1 1 welibox is crushed/damamd? 14 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> I <br /> Note below all defiencles that could not be correcled and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Perststlna Deficiency defers Correction to assigned corrected <br /> Mw,2A <br />