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BLAINE 1680 ROCKERS AVENUE NVELLREAD h4SPECTION CHECKLIST <br /> SAM JOSE,CALIFOR141A 95112 <br /> TECH SERVICES (409)573-7771 FAX t'.f18nt <br /> (408)573-0555 PHONE Equiva <br /> $�44��srr �0; Sfte Addrf 420ETTLEMAN LANE <br /> LODI <br /> Technician J <br /> Date <br /> - 1 - 00 <br /> i'vb pOC�i <br /> 1 Lia on box? 6 Casing secure' 12- Water standing in welfbox? 15 Well cap funcbonal? <br /> 2 Lid broken? 7 Casino cut levet? 12a.St2nding above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolls missing 8 Debris in wellbox7 12b Standing below the top of casino? 17 Can CaP seat out water? <br /> 4 Lid bolts stripped? 9 Wetlbox is too tar above arad0 12c Water even with the top of casino? 18 Padlock present? <br /> 5 Lid,5e,21 intact? 10 Wellbox is too tar belmi grade' 13 Well cap presenP 19 Padlock funcbon2l7 <br /> 11 Wellbox is crushedldamaged' 14 Well cap lound secule7 <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Correclive Action Taken <br /> r�• r' <br /> 2 3 S c�c`C <br /> .f <br /> y�r <br /> L <br /> F <br /> Hole below all dellel1C1e5 that could not be corrpcled and stilt need to be corr�-led <br /> BTS Otfice assions of Dale Dale <br /> Well t D Persistino Deficiency deters Correction to assioned corrected <br /> 0 — L/ ('//V;C— <br /> I <br /> i <br />