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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: !_1� vC 1r1Date: <br /> (dZ) <br /> Resident/Owner Name: 'I1,.,,� je <br /> Sampling Date/Time: _("7j—Q-- (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): <br /> Additional Well Info. (construction,pump depth) : Aleed _•I�o agao- t"t Sh - <br /> Well Use(last time used, purpose): 'Ll <br /> Sampling is limited to analysis for volatile organic compounds. Results of the samp ng program <br /> will be used to assess the need for future semiannual sampling events at your well. <br /> Acknowled ment: <br /> L.___..I Tiagree 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 /> 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: 2>a1j1a 405560 <br /> Remarks: <br /> Field Certification: Date: ZL- <br /> i \ <br />