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!� 4 <br /> WELLHEAD INSPECTION CHECKLIST <br /> Page I of <br /> Client Saf <br /> J1 Date <br /> Site Address 1 C1[b 4W-VL S P, C r , STd SIC <br /> Jeb l4umber \1 Z io-w1 S— Technician — <br /> Well Inspected- Water Bailed Wellbox Other Acton Weli idol <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Required Wellbox Cleaned Replaced Replaced (explain texplam Submitted <br /> beLmv below <br /> �- <br /> w\. <br /> NOTES <br /> QL"E rECA SEAMES INC SAM JOSE SACPAM1F-NrO lOS ANGr.LES SAPIDIEr,O w.+wt nnlec't�Cno, <br />