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Client/ <br />WELL CONDITION STATUS SHEET <br />Facility #: Chevron #9-4054 Job #: 17155216 <br />2103 Country Club Blvd. Event Date: Site Address: C 2 5 • I ) <br />Stockton, CA Sam ler: City: <br />_ <br />WELL ID <br />Vault <br />Frame <br />Condition <br />Gasket/ <br />0-Ring <br />Missing <br />(R) Replaced <br />Bolts <br />' (R) Replaced <br />1 A4) Missing <br />Bolt Flanges <br />B=Broken <br />S=Stripped <br />R=Retaped <br />Apron <br />Condition <br />C= Cracked <br />B=Broken <br />G=Gone <br />Grout Seal <br />(Deficient) <br />Inches from <br />TOG <br />Casing <br />(Condition <br />prevents tight <br />cap seal) <br />REPLACE <br />LOCK <br />Y / N Taken(M) <br />REPLACE <br />CAP <br />YIN <br />WELL VAULT <br />Manufacture/Size/ # of Bolts <br />Pictures <br />Y / <br />tviw411 ol< -...., <br />jt7 /0 rp-c-x7/8"12 <br />-1 ........- , / <br />4W -1C CV .....,....,_ <br />MW- (e Ov 1 -5 or ..______ 1 i-t.orit'sowaty- <br />mw• 7 (-9v -•>, 3-S nc .._ <br />r1/5041 ri ' 1 a --.....„... <br />Aito-di oie ---- 7 - 5 OY 1 _--- <br />miv ,qp 0 7- 5 c-91 <br />DRUMS PRESENT ONSITE? Y #: ARE DRUMS PROPERLY LABELED? Y / N LOCATION OF DRUMS: <br />nr.........