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WELLHEAD INSPECTION CHECKLIST <br /> Page V of <br /> Client 0ce,4 Date ' lo <br /> Site Address <br /> Job Number `�� ' r Technician <br /> ' Well Inspected- Water Bailed Wellbox Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below) <br /> � 1 ( <br /> VV <br /> 1 <br /> NOTES: I t/ r �Cc-PSS f'G► k) ! U /t Ye <br /> BLAINE TECH SERVICES.INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE www.blainelech.com <br />