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WELLHEAD INSPECTION CHECKLIST Pageof f <br /> Client rovs OU3 Date <br /> Site Address J1zJ °"" <br /> Jab Number / Tec nician <br /> —rC5a <br /> WELL IS <br /> Weil CLEARLY Other <br /> Inspected- WELL is Water <br /> Well Not <br /> P MARKED WITH Wellbox Action Repair <br /> No Corrective SECURABLE Bailed Cap Lock Inspected <br /> Action BY DESIGN THE WORDS From Components Replaced Replaced Taken (explain Order <br /> (12-orlers) "MONITORING Wellbox Cleaned {explain below Submitted <br /> Well <br /> Required WELL" below) <br /> V V ) <br /> ell I® (t2"nrless} <br /> Lt. ` u <br /> NOTES: <br /> BLAINE TECH SERVICES.INC. SAN JOSE SACRAMENTO LOS ANGELES SAM DIEGO mnv.NafneSech_com <br />