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1 R <br /> D0ULO8 ENVIRONK9MA a COXPAW SAMPLING INFORMATION SHEET <br /> Client:_U].=Mgr-. Sampling Date: <br /> Site: Beacon #695 Project No. : 94-695-01 <br /> 900_ S. Cherokee Tans dell Designation: RW- 1 <br /> Lodi. CA <br /> Is 3etug -of traffic control devices g aAire ? �� - ,�.imsP home <br /> X0 there standing gator in werl box? low TOC <br /> KA top -of c"ing out-ILOV*01 - r remarks <br /> Is Drell cap sealed and locked? remarks <br /> Height of well casing riser (in inches) : �- <br /> Well cover type: 80 UV 12 n UV 12 <br /> 12" BK 12 4° DWP 1211 CNI 367, C1 XI - - <br /> General condition of wellhead assembly: Excellen Fair Poor <br /> Purging Equipment: 200 disposable bailer Submersible pump <br /> 2� PVC bailer Dedicated bailer <br /> 400 PVC bailer Centrifugal pump <br /> Sampled with: Disposal bailer: Teflon bailer: <br /> paege Vol.. xult#l"ri;`i^'49 3RD - x{30�w J➢ `� `��`4, - _L '# r,' Q�i� t 4 y J J- _ <br /> fol C e L- r4 70 <br /> f-l5 C e 7 13 FrI -701f35 C7.3 13 y-5 G� <br /> Sample appearance: Lock; <br /> Equipment replaced: (Check all that apply) Note condition of replaced item <br /> 211 Locking Cap: Lock 03753 : 7/32 Allenhead: <br /> 410 Locking Cap: Lock-Dolphin: 9/16 Bolt: <br /> 611 Locking Cap: Pinned Allenhead (DWP) : <br /> Remarks: <br /> Signature: <br />