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f S . -•1 <br /> 1 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Equwva 98996189 Inspection date Y-,-c, 6J <br /> Site address 6131 PACIFIC kVE <br /> STOCKTON Inspected by 16 <br /> �amnle # <br /> BTS Event # ��L,'2s-Z cJ X I <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> _2_Lid_whoI0 _ 5a Standing above-well top? - 8-Can cap seal out water?------ -- - - <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 __Well cap/plug present? - 1 1-Padlock-functional?- -- — - - - —- <br /> Check box if no deficlences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> .l <br /> — - - - -Note=below-all=defictences that-could not-be corrected and st1fl need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to- assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />