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r <br /> 11 <br /> WELLHEAD INSPECTION CHECKLIST <br /> Page of <br /> 9 <br /> Client �s Date _ � L- <br /> Site Address o ice- - - - -- - - <br /> Job Number r93d- '� _ Technician _ <br /> Well Inspected- Water Bailed Wellbox Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well 1 D Action Required Wellbox Cleaned Replaced' Replaced -- (w Ain (explain Submitted <br /> exI� <br /> Zow 1� <br /> S <br /> t r53 X/ <br /> W i2.C�it 1� i f� 0-Att IC <br /> 14 <br /> f�lc✓�fs <br /> f <br /> 6 .� <br /> f ,C1 <br /> �gl �Q� !•ar a_� ��tw�L, 3f �/ <br /> BLAINE TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN CIEGO www bla'n°tach Com <br />