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w <br /> * i1 <br /> WELLHEAD INSPECTION CHECKLIST <br /> Page or <br /> Client S' Date <br /> Site Address 3 Ll S E <br /> Job Number Technician A/V\�C- <br /> Well Inspected- Water Sailed Wellbox Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> NOTES <br /> BLAINE TEC"SERVICE5 INC SAN JOSE SACRAIAE14TO LOS ANGELES SAM DIErU wvmtla1nhlatf1 CW' <br />