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WELLHEAD INSPECTION CHECKLIST Page_f of <br /> Client '' <br /> �--'ts'c.�..�:� Date <br /> SiteAddress <br /> Job Number Technician `- <br /> Well Inspected- Water Bailed Weilbox Other Action Well Nat <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> Well I® below below <br /> tigal'', <br /> 0' 211A <br /> X <br /> 10M'-?.IRA <br /> PAS —0(S; 'K t" <br /> .1—IA?N y <br /> ,AA,w_ <br /> 1`mi 'EC Y <br /> t f� <br /> °Sj- <br /> NOTES: j, , <br /> `-�`L �� s ,✓',�-r.S<r,, � ✓�TE�-e�§�r^ �c-°2 S�F:� ,ut���><nk A�t'�1,,;- ?Ps, = h� r3tC <br /> A:h,o!-i,A '—A % I$5 �trti 7'r�'- `�:+°t.'s,.!_ rs4sa? Alrl i-...`rt. <br /> BLAINE TECH SERVICES,INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE �+' +-blainerechggm <br />