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BLAINE 1Ba0 pOc;=ns AVE'-ius <br /> TEM 1 CERlIC-3 sAl r JcSc.CALIFORNIA 95112 <br /> {tDBt�75- 77f F.-Ax <br /> (4081 873-T555 PHOFIE Client (!�t! <br /> ��Ty. Site Addie5s Y 0 <br /> ' f <br /> •r � <br /> TechnicianDate 00" <br /> :1 <br /> 1. Uzi`.71 box i 6. C Gina se:ure, 12 Plgter stannrna rrr:vellEax:' , <br /> I rlgff ws3 luirctior,�,f' <br /> c" Lid Krol en r 1_ Gino cut levol: I yL ,vina-.Cove dte lev of czzina i 18. Can a he uf1_. <br /> 3. Ud bolls missing 7 B. Debris in welltox � R -s-1 laosa? <br /> I�h. roino befo:r itre lap of�'sina i 17. Carl c u se;j= arrt•;r� <br /> t.Lid bolts stripped% 9. `��ellbas is 4r�f-.1 abulp aide? 1^ _ ter: <br /> 2c Nater even:rii1•r Ole top of casing? 1B. psdfv ;present? <br /> 5.Ul+d SEL31 itIrE % 10. 'NeRbox is Ips f^-.r cPfor/atade? 13. 4�lelf=0 present. <br /> 19. PadEoch luriciioliaf7 <br /> 111-'Neffbox is crushedldarnaaede 114. 'Neff can found secure? <br /> Check box if no deficiencies were found. Mote belowaeflclerrcfe.,c <br /> yvu rJere afiie to correcE. <br /> Well I.E). Delicienc:` Corrective Action Taken <br /> I <br /> J <br /> jI <br /> 4 <br /> Mole below all defiencies tflat could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Dale <br /> 'rVell I.D. FerSi5tind DeficienC'I defers CarreCifon to: assigned corrected <br /> I <br /> I � I <br />