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s • r =7�7�t �+ <br /> BLAINE 1680 ROGEFIS AVENUE WELLHEAD INSPECTION <br /> TECH SErpVICE6.� SAN JOSE,CALIFORNIA 95112 • <br /> (408)573-7771 FAX Client �u( c&Q _ -75-),Y- <br /> f d+__ <br /> (4Q8)573-0555PHONE <br /> Site Address JZLb 07 UJIT 1`y__ M b - <br /> x - - <br /> Techrnelan S 4- OVA <br /> h Date r, 3 <br /> 1 Lid on box? 5 Casing secure? 12 Water standing in welibox? 15 Well cap tunctional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casino? 18 Padlock present? <br /> 5 Lid seal intact`7 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock funcbanaf? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br /> r <br /> ILI <br />