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WELLHEAD INSPECTION CHECKLIST <br /> Page of <br /> Client lil/2 5 Date U ' <br /> Site Address).r7.- SMC,?ccs u�rS 7� <br /> Job Number2-2-1- / - Technician (( <br /> WELL IS <br /> won Inspected-- WELL l5 MARKED WiTH Wellbox CLEARLY Water Action Well Not Repair - <br /> No SECURABLE Bailed Cap Lock Inspected de <br /> Corrective�e BY DESIGN "MONITORING <br /> WORDS From Components Replaced Replaced Taken (explain Order <br /> Action (12-wtanj NITORING Weg6ox Cleaned (explain below) Submitted <br /> Required WELL" below) <br /> Well ID +��-� ► <br /> �E s OAJ- <br /> 4�6 61 <br /> 3 - <br /> �3 <br /> NOTES: <br /> BLAINE TECH SERVICES INC SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO www.dalnetedh com <br />