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07� <br /> 1680 ROG ERS AVENUE WELLHEAD INSPECTION CHELkL18T <br /> BLAINE SAN JOSE,CALIFORMA 95112 <br /> TECH SERVICES. (4013)573-7771 FAX <br /> Cttenl ��(-f� <br /> (408)573-0558 PHONE <br /> Sete Address Z C3' L'J <br /> z Technician M,r -V,- S <br /> 0 <br /> 'rte �T Date Z.-L- w), <br /> 1 lad on box? 6 Casing secure? t2 Water standing in weflbox7 15�Nefl rap_ftmctfanal7 - <br /> 2 1ld broken? 7—Casing cut levef7 12a.Standing above the top of casing? 16 Can cap be puffed loose? <br /> 3 Ud bolts missing? 8 Debns in wellboxl f 2b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Weffbox is too far above grade? 12c Water evert with the top of casrng7 18 Padlock present? <br /> 5 Ud seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 1 Wellbox is aushedldamaged7 14 Well cap found secure? <br /> Check box it no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> IV, I, fv <br /> e +.. G Z 3 r tom•,, <br /> Note below all deftencies that could nol be corrected and still need to be corrected <br /> BTS Office assigns or Dale Date <br /> Well I D Pefs1sting Deficiency defers Correction to ass ned corrected <br /> l <br />