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BLAINE 1699 FloGEFI7 AVEIdad <br /> WE VELL . AD ju,;SY c �Y�+L. <br /> pECTIO 1 �j�11��'! <br /> SAI I JOSE CAUFORrIIA 55112 <br /> TECH SEBVrCES._ (108)$73 7771 FAX <br /> Client ZvA-I <br /> (408)573 0555 PHOMEi 1 _ <br /> SO Address tt� <br /> c d' hi 1 r �,i 1 24 <br /> Technician <br /> �= Date <br /> 1 Lid en bar: 6 Casvro secure' i2 Water standing in%velibox7 15 Well cap functional? <br /> 2 Lid brol•en i r'Casrng cvt level? I&L Standing above the top 01 casrngl 16�Can pp be prlffed]Dose' <br /> 3 lid bolts inissrna7 9 Debris h wellbox7 12b Standing Wow Hie top of castna 1 17 Can cap seat otrt water- <br /> ,4 Lid bolts strrpped' P Weffbox is too far above grade 7 12c Water even with file top et casino i l8 Padlockpresenl7 <br /> 5 Lid seal intact' iR Wellbox rs too far Leloti,grade? 13 Well cap present? 18 PadIOCk funCiponal7 <br /> I I Vdellbox is crushedldainaged7 114 Well cap laund secure 7 <br /> Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> b"fell I D Deficiency Corrective Action Taken <br /> dole below all deliencies that could nv( be correcled and stiff need Io be corrected <br /> BTS Office assl[]ns or Dale Date <br /> Well I L) f eisislinq Delicienry defers Correction to assi ned corrected <br />