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WELLHEAD INSPECTION FORM <br /> Client: rCe aC Site: ( g1 ,� , /,���cl��� Date 20-v8 <br /> Job#: 0 XC's�jTechnician: /�°/ ' has ) e Page t of <br /> Check Indicates deficiency <br /> m w <br /> _ - v <br /> Z m m E d <br /> _ - N <br /> m m _ � d Notes <br /> C O P O N m C <br /> " ¢ —, — — n d E 15 <br /> ;� m — _ (list if cap or lock replaced,if there are access <br /> S °c E E ° c issues associated with repairs,if traffic control is <br /> 75 <br /> Well ID w m E E 9 ° c z n required,if stand pipe damaged,or any specific <br /> �i rj v mn t- ¢ ¢ �`- m O 3: m <br /> details not covered by checklist) <br /> �a <br /> Notes: <br /> BLAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE wv+w.blalnetechonn <br />