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1 <br /> ELAINE 1560 ROCLr•,b ir AVEVuYY ^LLIMA-D L ff"EC !I'O CIMCK <br /> C CK <br /> SAN JOS'c CALIFORNIA 95312 <br /> TE:H MUIVIC 3 (405)57U-7,77 I FAX C€Fe-it_C3w: <br /> (408)Sr 3-05 c PHONE - � tt�1 tol� <br /> _ <br /> 1oQb ;r � Slte AdalEE3 <br /> Dateor7 <br /> 1 Lid on box? 6 Casmg semre 7 12- Water standing in w0bax7 1E Well r:-o hmctrdna17 <br /> 2. Lid broken? 7 Casing tart leve» 12a Stattdina above the too of casmd' 16 Can cao be pulled loose? <br /> 3 Ltd belts rnissing7 8 Deans in weflb=7 12b Standing below the top of Casino 17 Can cap sea out w-512r7 <br /> 4 Ud bolt$strroped7 g Werlbox rs be fat acove grape 2 t 2c Water even with the too of c rima' 16 Pacloc't present" <br /> 5 Lid seal intact? ---- f0-Wellbox is too far bercw oracle 13--Well cad present*7-- - ,_ � 19-Paoloek functional' <br /> 11 'Neflbox is mzried/damaned7 14 Well epm found secure? <br /> Check box if no deficiencies were found Note below aefcienmes you Were able to correct <br /> Well € D Defic:erlcv Corrective Action Taken <br /> y <br /> � I <br /> y <br /> i <br /> Nole below all defiencies I11at could not be corrected ana still nem to be correcied <br /> t � <br /> BTS Office ass:ans or ©ale Dale <br /> Well I D Persistrna Defrc:erlc4 defers Correction to assioned corrected <br /> V � <br /> i <br /> V � <br />