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WELLHEAD INSPECTION CHECKLIST Page of � <br /> Client Cc r a.-5 Date all!a Z1, <br /> Site Address <br /> Job Number Technician M-'e— Laiff SC <br /> Well Inspected- Water Baited Wellbox <br /> Other Action Well Not <br /> No Comective From Components Cap Lock Taken Inspected Repair fiOrder <br /> tted <br /> Well {® Action Required Well Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> MW-01A X <br /> MW-01B X <br /> MW-01C <br /> MW-02A X <br /> MW-02B X <br /> MW-06A K Z!' <br /> MW-07A 1� <br /> MW-08A r"£ <br /> MW-08A <br /> MW-10A <br /> MW-11A X <br /> MW-12A <br /> MW-12B <br /> MW-13A K <br /> MW-13B <br /> MW-14A X <br /> NOTES: <br /> B!-AINE TECH SERVICES,INC. SANJOSE SACRANIENrO LOS ANGELES SAN DIEGO SEATTLE www.blainefe:h.com <br />