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n <br />DOMESTIC/MUNiaPAL SAMPLING PROGRAM <br />N% -Of WELL ACCESS SHEET <br />Address: Date: -7 <br />i <br />Resident/Owner k <br />I <br />Sampling Date/rime:r I (Estimated sampling time Is 15 to 20 <br />Access Issues r � <br />• Animals/Pets, <br />Additional Well Info. (construction, pump depth):I <br />JlWell Use (last time use...o <br />Sampling Is limited to anaIVsIs for wolade organic compounds. Results of the sampling program <br />4 <br />vAll be used to assess the need for future semiannual sampling events at Vour well. <br />I agree to participate In the Forward Landfill Domestic Well Sampling Program and <br />authorize <br />j, <br />I <br />sampling. cost to me. I understandbe ♦i• �. with <br />a report with the sample results when they are available. Additional sampling may occurF <br />semiannually, and <br />• r.- rsamplingevent, o,. <br />4 - <br />1 <br />E= I do not need to be present during the sampling event. <br />I do no agree to participate In the Forward Landfill Domestic Well Sampling Program. <br />• C ` <br />Ix r►�► <br />�� <br />