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. WELLHEAD INSPECTION CHECKLIST page of C <br /> Cheat Date <br /> Site Address Ilb6 vi, jdsyAt a ►AkAitr'.GA <br /> Job Number 66o7w3 - r"M t _ _ Technician T. A4,-t <br /> WELL IS <br /> Well WELL IS Water CLEARLY Other Well Not <br /> Inspected- MARKED WITH Wellbox Action Repair <br /> N SIGSECURABLE Bailed Cap Lock Inspected <br /> No Corrective BY DETHE WORDS Components Taken Order <br /> Action (t2' SIGoriess) "MONITORING From romx Cleaned Replaced Replaced (explain below)(explain Submitted <br /> Required WELL" Wellbobelow <br /> Well ID <br /> M,W—f .ti x k <br /> AAWf2- 1C 1C. <br /> uV' � h S• <br /> NOTES ox ti VJ iT9V�. n klc t{ Ise a ot�p <br /> SoMka+uE rLACED VOX Ld fjo MAlZ-I`-QJ -d v0sEcu2o-g'l OJf-K $d. <br /> BLAINS TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN D(EGo www bhinetwh cpm <br />