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r <br /> WELLHEAD INSPECTION CHECKLIST page--t—of <br /> Client KfAff AH-IM ►tat Date b 1- It <br /> Site Address _oto\C Eleleaw� S:\e Wk.s�¢y Stowch (�,aaf Cts <br /> Job Number hobo\ -- KIL Technician <br /> Well inspected- Water Bailed Weilbox Other Action Weil Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Action Requiretl Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> N <br /> r <br /> r <br /> r <br /> r <br /> r <br /> NOTES: <br /> r <br /> r <br /> r <br /> SLAINE TECH SERVICES,INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE www.blainetegi ram <br />