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DOULOS ENVIRONMENTAL, INC. SAMPLING INFORMATION SHEET <br /> CIient Ultramar Sampling Date - = <br /> Site Beacon #3641 Project No <br /> 1210 E Hammer Lane 1400 Well Designation <br /> Stockton,Ca <br /> Is setup of traffic control devices required? KO YES time hours <br /> Is there standing water in the well box? NO YES Above TOC Below TOC <br /> Is top of casing cut level? NO YES If no, see remarks <br /> Is well cap sealed and locked? NO YES ` If no, see remarks <br /> Height of well casuig riser(in inches) <br /> Well cover type 8" or 12"UV 12" EMCO 8" or 12"BK 8"Ch isry <br /> 12" Christy_ 8"M&D 12" M&D 12"DWP <br /> 12"CNI 36" CNI 12"Pomeco Other <br /> General condition of Nrellhead assembly Excellent Good • Farr Poor <br /> F <br /> Purging Equipment 2" disposable bailer Submersible pump <br /> 2" PVC bailer Dedicated bailer <br /> 4"PVC bailer Centnfugal pump <br /> Sampled with Disposable bailer - Teflon bailer Disposable Tubing <br /> Well Diameter 2" 4" 6" g" <br /> Purge Vol Multiplier 0 16 0 65 1 =17 2 6I gal/ft <br /> Initial Measurement Recharge Measurement <br /> Time `% _- <br /> Time Calculated purge �- • -� <br /> Depth of well Depth to water Actual purge <br /> Depth to water <br /> / r � <br /> Start purge / r' Sampling time <br /> PTp.e Temperature E C H Turbidity Volume <br /> �r In <br /> ~ <br /> A <br /> Sample appearance r"-e r Lock <br /> Equipment replaced (check all that apply) Note condition of replaced item(s) <br /> 2" Locking Cap Lock 7/32 Allenhead <br /> 4" Locking Cap Lock-Dolphin 9/16 Bolt <br /> 6" Locking Cap Pinned Allenhead (DWP) <br /> Remarks <br /> Signature <br />