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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> • Client Site# Inspection date 1 Yg a <br /> WRIGHT <br /> Site address ENVIRONMENTAL Inspected by A) • alt _ <br /> M&M AUTOMOTIVE <br /> 60 E 10TH ST,TRACY STS Event # t3t Ly 6 of <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? i Can cap be pulled loose? <br /> 2 Lid whole's 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 intactl Sc Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> ❑ Check box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> (,./— I o r-1< <br /> I <br /> i <br /> I <br /> I <br /> I i I <br /> Note below all deficcences 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 /> IMt�-Z{!1 m1� L..'1Allam_._ I ! <br /> o —1-2 Ci M <br /> I <br /> I I <br /> LG I <br /> • I I I <br /> Office review and assignments made by Cate <br /> Blaine Tech Services, Inc File WELL CHK s <br />