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i <br /> 1680 ROGERS AVENUE �LLUEA-D`li-ISr ECTIO CBECKLISTBLAINE r I t] <br /> SAM JOSE CALIF{7RMIA 95112 <br /> TECH SF-rIV1CSS— (d08)573-7771 FAX Cllerlt egycv ti <br /> (408)573-0555 PHONE — - <br /> q� orf°d Site AddreSs `I tId w• C�4r *�r %,Wily 5}y c te., <br /> Temnictan PA r:C+ F. <br /> � t <br /> Date 3 '16-d e- <br /> i Lo on ocx7 6 Casma secure" 12 Water standing in%veilbox7 iS Neil mu functional- <br /> s2 Ltd broken 7 7 Casing cut level? 12a-5lanaing anove the top or cz-astna7 16 Can cup be pusled loose' <br /> 3 Lro bolts mrss=7 8 Debns in wellbox7 12b 5tanornu below ten o of casma7 17 Can caD seal out wate,: <br /> 4 Lid baits strropeo'7 4 Weilbox:s too far above grace 7 12c Water even with the too of r;ssng 7 18 P_ofoC' presar:it7 <br /> 5 Lo seal rntacr7 10 Weflbox is too 1w belov araee7 13 Weil cac present? 19 Paciocx func3onaf7 <br /> 11 'N&Ibox is=snedldamacea% 14 Well cm found searre <br /> Check box if no deficlericies were found Note below deficiencies you were able to correct <br /> h <br /> Well 10 Deficiency Corrective Action Taken <br /> } <br /> i - <br /> J <br /> I <br /> J <br /> l <br /> t1ole below ail deriencies that could nol be correc+eo ano still neea 10 be correclea <br /> 8T5 Offlce a55 onS or Date Date <br /> 'Nell I D Perslstlna Dertcierlc� de+erS Corrtx-fion to ass,ane❑ corrected <br /> 6 h , 0-FP- wt I) 6eA <br /> hNe i� yo re C /QC,gI u ! I <br /> -17 <br /> \_y <br />