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BLAINE 1684 nOGER9 AVEI7VE WELLHEAD ]INSPECTION Cl-W-1 <br /> 5Al I JOSE CALIFORNIA 95112 <br /> TECH SE[tVICES.> [14@)573 T771 FAX Client_ V� <br /> • air y [108)573 0555 r i-lolle <br /> SO Address—W d A a �,L �c� S L� <br /> '4t _ <br /> z <br /> Technician <br /> �rtt g� Date o _— <br /> ,\ <br /> I Lid rn loot- B Casrrra secure,' 12 Water standing in tveflbax7 15 >Plell cap luncbonal7 <br /> 2 Lid broken- 7 Casino cut level' 112a Standing above dip top of casino? IB Carr cap be pulled loose- <br /> 3 Lid bolts missmu" R Debris in tivellbox i 12b Standing below The top of casino 7 17 Carr COP seal out Water,' <br /> ,`! Lid bolts strrpl+4d% 9 Weflbox is Inc far above grade 7 12c Water even with Ute top of casino 7 16 Padlock presprrt7 <br /> 5 tad sea[intact: 10 WeRbox is Ica far beloNi grade2 13 Well(--p present- 19 Padlock funchonal- <br /> I I Wellbox is mushed1danraged7 14 Weil rap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> i <br /> i <br /> i <br /> 1 Pole below all deflerjuies Ilia[ could nol be corrected arid still need to be coirec[ed <br /> B TS 0II1Ce assigns or Kala Dale <br /> VVefl I D r-eisisting Deficiency defers Correction to asslOrled colrecled <br />