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C�A <br />E <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />6&72 Q"/ Date: 6 -2-Ai-, / <br />sident/Owner Name: r k"s ± c--% <br />mpling Date/Time: qL%fl'f 1/ -1 (Estimated sampling time is 15 to 20 minutes) <br />- T--------r—T <br />Issues (Locks, Animals/Pets, Other): <br />ional Well Info. (construction, pump depth) : <br />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 />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 />semiannually, ADA <br />I must to be present during the sampling event, or <br />I g 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 />nature: <br />nt: 1 V 15 V\ k <br />marks a <br />1 -IG i <br />Id Certification:FrZ 11 <br />Date: <br />