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��t r�,ry�T CHECKLIST <br /> BLAINE lana ROGERS AVENUE WELL AD �.NSPEC 3�'Lll�f LHECKLI�1 <br /> BL SERVICES.. SANJ❑SE.CALIFOFI141A 95112 <br /> taaal. a--,rri FAx Ment rr4 a 1./4-7 <br /> nr (4o6)9:3-055a PHONE <br /> • Site Address AW th r <br /> Tecilniciarl 69 r <br /> Date i LIl.�t 1r <br /> I !id on box? 6 Casing serxrre 7 12. Wafer standing in weflb=? 1s Well cap hrnctiarral? <br /> 2 Lid broken 7. C.irra cult level? 12a Starrcifrrg above the hrap of casing? 1a Can c—.p be pulled loose? <br /> 3.lid ImIts rnissirw 7 a Debris In welfbox? 12b Standing below the Fop of casing? 1T Can cap sea:out water? <br /> 4.tld boft strfpped7 9. Wellbox is too lar above grade? 12c Water even wfEh the top of casing 7 is Padlock preset? <br /> 5 Ud seal Intact? io.Wellbox Is too far below grade? 13 Well rap present? 19.Padlock kmilorral? <br /> 11.Wellbox Is crushevJdamaged? 14. Well c-p found semtra? <br /> E26 Check box If no deficiencies were found_ Dote below deficiencies you were aBle to correct_ <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all deiiencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Dale Date <br /> Well I D Persisting Deficiency defers Correction to: assigned corrected <br />