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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Inspection date S^7-0:!Z2 • <br /> Equrva 204-7524-2408 <br /> Site address 4445 N PERSHtNG AVE Inspected by <br /> STOCKTON <br /> BTS Event# GI'_�5� 7 — �Z <br /> 1 Lid on the box? Yes No 5 Water standing ,n the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug presents 11 Padlock functional? <br /> ❑ Check box if no deficiences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all deficlences that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br /> til LI ��c�5 Z 3 -T-5 6J, <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />