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DfMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: Date: <br />Resident/Owner Name: ad/12, <br />Sampling Date/Time: 10 l (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): Manz <br />ditional Well Info. (construction, pump depth) <br />Use (last time <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 />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 />I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />I do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />ignature: P Cay I G <br />Print: <br />l <br />Certification: <br />Date: <br />