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BLAINE 1530 ROGE: HvENUE NVELLiEAD -'ECTION CHEC•KL <br /> SAN JOSE CALIFORNIA 95112 <br /> TECH SERVICES t (4t)8)573-7771 FAX CtlBnl r ..t• ^ <br /> air pis ttr�A (408)573-0°SS PHONE <br /> Site Address QI <br /> Tecftnician <br /> —S4rormr) -------------- <br /> Date <br /> Nr� pp��S <br /> I Lid ori box? Fl, 'Nellb'ox <br /> sino secure 7 12 IN 18r standina in%venbox7 <br /> 15 Well rap IuncUonal7 <br /> 2 Ltd 6rdken� srnalt level? 12a Standing above the top of casino? 16 Can cep be Puffed loose <br /> 3 Lid bolts mrssrng7 bns in wetlbox7 12h Standing below the to di castnd� <br /> P 17 Can can seal out water"7 <br /> 4 Lid bolts stripped? tfbox is tad(,J above grades 12c Water even with the 10 of casino? Il <br /> P !t3 Padlock presenr� <br /> 5 Lid seat intact- llbdx is too far belm grade'2 13 Well cap present? <br /> 19 Padlock funcdAnal7 <br /> rs ensshedfdarnaged� 14 Merl cap found seuue <br /> 0 Check box it no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Dehcienc/ Corrective Action Takers <br /> kc- <br /> Mote <br /> below all deftencies that could not be corrected and still need to be corrpcled <br /> OTS Office ass:qns or 0;319 Date <br /> WF-311 1 D Pelsislino Dericse-icy defers COfrecfton to <br /> assioned corrected <br /> J� <br /> l <br /> f <br /> I <br /> I <br />