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vvtL.LH ` INSPECTION CHECKLIST AND :'AIR ORDER <br /> - <br /> Client Inspection Date o '- <br /> Site Address L' j f5. �.;•, A. &0q Inspected By <br /> Q <br /> d an box? B. Casing secure? 12, Water standing In wsiibax7 i5.Wep cap functional?Lid broken? 7. Casing cut level? 12a:Standing above the top of casing? 18.Can cap be pulled loose? <br /> % <br /> a.Ltd bolts missing? a. Debris In welbox7 12b.Standing below 1he top of casing? 17.Can cap seal out water? <br /> 4.Lid bolts stripped? U. Wellbox Is too far above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> S.Ud seal Intact? 10.Wellbox Is too for below grade? 13. Won cap present? 19.Padlock tunctiorud? <br /> 11.Wellbox Is mtsheMernaged? 114. Weli cap found secure? <br /> 0 Check box if no'deficlencles were found. Note below deflclencies you were able to correct <br /> Well 1.D. Deficiency Corrective Action Takers <br /> r1ry-1A tS b•A ca 1 d It a cAftJ ra tJ 1 �� t ) a IL 1. <br /> Note below all defiencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persistinq Deficiency defers Correction to: assigned corrected <br />