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T ��Tr A n * �r T� fn <br /> BLAINS 1580 FlOGERS AVE14UE YVELL_R7EAD b-48PECTIO CIll'all'J[7►1�'1t'!T <br /> SAH JQSE,CALIFORMA 95112 <br /> fECN SEAVTCEB-y (408)573-7771 FAX Client_��� <br /> {4081 573-0555 PONE <br /> Slee Address_ <br /> Technician <br /> T Date <br /> I Lid on box? 6 Casing secure? 12 Water standing in welfbox7 15 Well cap lunctlonal7 <br /> 2 Ltd broken? 7 Casing tut level? 122.Standing above the top of casmg7 16 Can tap be pulled ioose7 <br /> 3 !id bofts missing? 8 Debris in wellbox? 12b Standing below the Bop of casing? 17 Can cap seal out water? <br /> 4 Lid bolts otpped7 9 Wellbox is too Far above arade7 12c Water even with the tap of casmg7 IE Padlock present? <br /> 5 Ud seal intact? 10 Weltbox is too tar below grade? 13 Well cap present? 19 Padlock lintcbonaf? <br /> 1 I Wellbox is crushed/damaged? 14 Well cap found secure? <br /> 0 Check box if no deflciencles were found Note below deficiencies you were able to correct <br /> 'Nell I D Deficiency Corrective Action Taken <br /> 1r+lW r]eA. <br /> Note below all defiencies Ihat could not be corrected Intl still need to be correcled <br /> I <br /> BTS Office assigns or Dale Dale <br /> Wefl I D Persisting Deficiency deters Correction lo asst ned corrected <br /> ,i k <br /> - C, <br /> I <br />