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BLAINS isso ROGERS AVEME W LL�3fE" h-iSPECTION CBECKLIST <br /> SAN JosE CALIFORNIA 95112 r <br /> TECH SERVICES— (408)573-7771 FAX Client FAr✓OVt Q tr <br /> (4013)573-0555 PHONE I ~ <br /> j "moo Site Address YYd W. �v <br /> zo' �tri <br /> Technician "e 6, Sly PIMA <br /> w z <br /> Date CA&0 V <br /> I Lid an box? 6 Casing securer 12 Water standing in vellbox7 t5 Well c5p functfcnat7 <br /> 2 tid broken? 7 Casing cut level-, 12a.Standing above the top of casrng7 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 13 Debns in welrbox 7 12b Standing Wow the top of oasing7 17 (;an cap seal out water-, <br /> 4 Lid baits stripped' 9 Wellbox is too far above grade 7 12c Water even with the top of casmg7 19 Padlock present? <br /> 5 Lid seal intact' 10 Wellbox is too lar below grade 13 Well cap present^ t9 Padlock functional? <br /> 11 Wellbox is aushedldamagef 14 Well cao found secure? <br /> 0 Check box if no deficiencies Were found Note below deficiencies you were able to correct <br /> 'Neil I D Deficiency Corrective Action Taken <br /> Mote below all defiencies dial could not be corrected and still need to be correu-ted <br /> BTS Office assigns or Dale Date <br /> Well I D Persisting Deficiency dele Carr t10 assr rled corrected <br /> �7w-� wEu. BO>t <br /> ae A10 E w GI1f Z <br /> RIC 6r NVWOV: 44954 5 v <br /> • <br />