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• ' ` ELAINE 1680 ROGERS AVENUE WELLHEADL-tSPECTION CHECKLIST <br /> TECH SFNIVICFS.. SANJOSE CALIFORNIA 95112 �7 <br /> ((-200) 2 <br /> 0B)573-7771 FAX Client oG/ `• ! � 2 5- 6 1 <br /> (408)573-05533 PHONE <br /> Sfte Address9131 <br /> Technician <br /> Date_ $-a+ <br /> iNb OO�� <br /> 1 Lid on box? 6 Casing secure, 12 Water starrdna to rveffbox7 is Weil c--p functional? <br /> 2 Ltd broken? 7 Casino cut level? 123 5tandina above the top of Erna? 16 Can(--p be pulled loose? <br /> 3 Ltd bolts mrssing? 8 Debris to wellbox 7 12b 5tandina below the top of canna 7 17 Can cap seal out water? <br /> 4 lid bolts stripped-2 9 Welfbox is too tar above arade7 t 2 Water even with the too of casino? 18 Padlock present? <br /> 5 Lid sea)intact" 10 Weilbox is too Far befow grade 13 `Ned cao present' to Padlock lunction217 <br /> I 1 Wellbox 1s c ishedldamaaed" 14 Well caD found serge? <br /> 0 Check box it no deficlenc)es were found Note below deficiencies you were able to correct <br /> I <br /> Well I D Deficiency Corrective Action Taken <br /> I <br /> tJole below alt defienctes that could nol be correclecj an❑ stili nem to be corrected <br /> 2TS Office assigns or Dale Dale <br /> Well I D Persistino Deficiency eefers Correction to assioned correcied <br /> nw- � <br /> • ! I I <br />