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1r� <br />u <br />DOMESTIC/MUNICIPAL SAMPLING PROGRAM •'. • ,. <br />WELL ACCESS <br />Address: Date: <br />Resident/Owner Name: <br />Sampling Date/Time: 4 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <br />Additional Well Info. (construction, pump depth) <br />Well Use (last time used, purpose): t <br />Sampling Is limited to analysis for volatile organic compounds. Results of the sampling program <br />will be used to assess the need for future semiannual sampling events at your well. <br />Acknoledament: <br />I agree to participate in the Forward Landfill Domestic Well Sampling Program and <br />authorize sampling of my well at no cost to me. I understand that I will be provided with <br />a report with the sample results when they are available. Additional sampling may occur <br />semiannually, and <br />I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />1 dg ngt agree t rticipate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks <br />Field Certification: Date: <br />