Laserfiche WebLink
DOMESTIC/MUNICIPAL SAMPLING <br />1 ! PROGRAM ! O ! L: <br />N%.Oe WELL ACCESS SHEET <br />6j <br />9� <br />Address: (05(2 00 SnylF\"Ol N11 -C Date: G _ Z— /-7 <br />Resident/Owner Name: La=n PI 161P/Y"-' <br />Sampling Date/Time: 1 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other): <br />Additional Well Info. (construction, pump depth) : <br />Well Use (last time used, pur ose): <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 />nts <br />150 <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 />semiannually, and <br />171 I must to be present during the sampling event, nor <br />I do not reed to be present during the sampling event. <br />I dg agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Irxv>C ► i ch <br />EX— <br />Remarks: _ C ` <br />-- Loe <br />Field Ce an- Date: <br />