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DOMESTIC/MUNICIPAL WELL SAMPLING Y <br />WELL ACCESS <br />Address: Date; <br />Resident/Owner Name:�d//� CA AV 4 ff , a, 4P/' `cvl t ,- <br />Sampling Date/Time: O L45 (Estimated sampling time is 15 to 20 minutes) <br />Access Issues (Locks, Animals/Pets, Other); AJ& a Sgapm e.o ko ow, Atp_ <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 />Acknowled ent: <br />l 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 />[E�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 Programa <br />a <br />Signature: <br />Print: <br />Remarks : -7 <br />/4! - <br />Field Certification: Date: <br />