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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />• <br />Address: y 3L Avcb cna A Date: lP /2147 <br />Resident/Owner Name: [� � 4 a� <br />Sampling Date/Time: Q 11-1 00 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): y h►vim F.e-ylc,,-- % v Pc'y\ wcA �--� <br />Additional Well Info. (construction, pump depth) <br />Well Use (last time used, purpose): PES -4- 1rr\aiot v1 <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 />Acknowledgment: <br />EA,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 />s miannually, and <br />I must to be present during the sampling event, or <br />Q I do not need to be present during the sampling event. <br />aI do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: iZ A Pv-- CAA I kC3 <br />Remarks4 '7 <br />Field Certification: Date: sdaz <br />-+� SpG.r,►�11 Spic-�1�-��nc.' <br />C-xy <br />