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WELLHEAD INSPECTION CHECKLIST Page_ 7 of I� <br /> Client ( Date <br /> Site Address f' <br /> JobNumber ttOIIZZ-zYU'l Technician <br /> Well Inspected- Water Bailed Weilbox Other ActionWell Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Weilbox Cleaned Replaced Replaced explain explain Submitted <br /> below below <br /> 1-3,5 <br /> NyS_MA <br /> AA'-N5 111 <br /> ,%VS- 'S A <br /> ;MILS ""SC; <br /> rata-t5u �' <br /> IX <br /> NOTES: <br /> BLAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE www.niainetechcvm <br />