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WELLHEAD INSPECTION CHECKLIST Page € of E <br /> Client A<y c:5 Date % LZS X I <br /> Site Address cc cid 4 (p,"" s} ` Lc # Cry <br /> Job Number Technician 3 <br /> Well Inspected- Water Bailed Wellbox OtheTr Action Well Not <br /> No Corrective From Components Cap Lock ken Inspected Repair Order <br /> Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> Well ID below) below <br /> Mw-I <br /> Pal —G197 <br /> Aw A <br /> M A <br /> NOTES: <br /> BLAME TECH SERVICES,INC. SAN JOSE SACRAf9EN10 LOS ANGELES SAN DIEGO SEA'T"ILE vr.+rwDlainetS;L w.ri <br />