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ENVIRONMENTAL WELL,REMEDIATION COMPOUND,AND SITE INSPECTION FORM Pao. 'Z— of <br /> INCIDENT* -Tqqc? 63q ADDRESS /adS5 V'0-w1r,, 1A"'5RMV-j <br /> DATE! 15--177 C"&STATE <br /> Observallons'Upo <br /> Well labeled! Well Cap We WPjd I a a 0 0Repair <br /> Well ID Manway Cover,Type,Condition&Size P.Imed Well Lock DittailedExplanation ofMaintenanceRairspinended We and <br /> (Gripper) and Performed Condition Initials <br /> property' Condition <br /> Pill <br /> Siae(inch) <br /> HWHO tandiall >Flush G P Y N G R G R NL Y N <br /> Ed�pl;�Flush G P N R R P Y /N <br /> — (9 NL ) <br /> 01 L <br /> !Ed:p Flush (9,) P <br /> N R R NL CG P Y <br /> Kt:.:.dPRla Flush P UV N R It NL P Y DN <br /> RU) <br /> P N OG R R NL P Y-13 011`v�-d:j�' lush 6 <br /> sin(lat <br /> ffWj- qa tari lush G P r R Y Pi <br /> /7 Y N a NL G P <br /> !Ed>p. , S P N G R G NIL P Y <br /> Slee mnhf <br /> 1� <br /> Ct.Dndp-.p Flush G P St.(0.10 N R a R NL nG, P Y <br /> Size(iroh] <br /> Standpipe Flusl. G P Y N Q R 0 R NL G P Y N <br /> Sba(I..h) <br /> StandpipelN <br /> i Flush G P Y N G R G R L G P Y N <br /> l <br /> S1.11r.h) <br /> Standpipe <br /> Flush f G Y N GR 0 1'— NL G P <br /> TOTAL#CAPS REPLACED <br /> TOTAL#OF LOCKS REPLACED <br /> _krdl� <br /> 6 G Nl LAO. <br /> P <br /> .......... 777-7� <br /> R lRepalmliec'�mend L 6;it amd6o <br /> ............. <br /> Cl. Irm 0 n <br /> NA I YL <br /> Building I / <br /> Building wl Fence Cc NIA G P dNIA G Y NIA <br /> 7� G P— 1--=- P <br /> Fenced Compound <br /> Trager <br /> Photos or <br /> LabdedC.r,r.flyrrd Omer's Laceted U,Wn Ire <br /> In,Z.tral to Dt,Wird E.&r.V..of Any[...a Resolved Drum alt <br /> Writing Legilite Business 1ntaeeMn,,x,. <br /> Frw.r..rn.d i cond V011b. antlPMI in 1 <br /> 0Y I N NIA G p NIA N Y N WA Y N <br /> G=Good(Acceptable) R=Replaced All environmental walls and the reareclaffort compound were in good candyffon, <br /> P=Poor(needs attention) NL=No Lock Required lacked,and secured upon my departure(unless otherrylse noted above). <br /> Notv-All mralm other than looks and adApers renule,Shall Wit npp—1 prior ke brair <br /> Na <br /> Version 2A,MM NOB Print or type me or meta Person el&Consultant <br />