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DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: f��,�frs/►'lA+�i Ip0 Sly Date: <br /> Resident/Owner Name: j?YV 1.du D � ��`t2V <br /> Sampling Date/Time: 6,/ (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): (-�,L oS�c! /i►1rea/ 'Vr ss' <br /> e rti�� <br /> Additional Well Info. (construction, pump depth) <br /> Well Use(last time used,purpose): <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 /> Acknowledement: <br /> Ilit�I 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 /> miannually,and <br /> must to be present during the sampling event,or <br /> I do not need to be present during the sampling event. <br /> F-11 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br /> Signature: <br /> Print: 49M AIV �e f/� � r✓D <br /> Remarks: 140 <br /> Field Certification: - Date: <br /> • <br />