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l <br /> t ' I <br /> S <br /> BLAINS 1680 ROGERS AVEWE NVELLH�+` " b"ISPECTION CBE+ CK,ZST <br /> TECH SERVICE SAM JOSE CALIFOR141A 35112 f <br /> (400)573-7771 FAX Client C' /07{dOB)573-tl555 PHONE <br /> SO Address 3 7 k5— <br /> Technician <br /> Date P,/3/,,,D <br /> 1 Lad an box? 6 casing secure? 12 Water standing rn wellbox7 IS Well cap funchonal7 <br /> 2 Ud broken? 7 as <br /> cart level? 12a Standing above the top of casing? t6 Can cap be pulled loose? <br /> 3 Lid bolts missing? B Deb 1s in wellbox7 12b Standing below the top of castng7 17 Can r;ap seal out water? <br /> 4 lad bolts shipped? 4 Wellbox is too far above arade7 12c Water even with Ilse top of casing? Is Padlock present? <br /> 5 Ltd seal intact? 10 Wellbox is too far below grade-2 f t3 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged7 14 Well cap 1ou11d serge? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> W�3� '"Cw <br /> r _ _ <br /> Hole below all deliencies Ihat could not be corrected and still need to be corrected <br /> BTS Office assigns or Dale Date <br /> Well i D Persisting Deficient de 0io lion ass ned corrected <br /> 14 Ii- a � �h J-e_ <br /> 7 <br />