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TIOPROGRAM <br />WELL ACCESS SHEET <br />} D..:.. i <br />Date/Time: 4;WJ; -7 sampling time Is 15 to 20 minutes) <br />Issues (Locks, Animals/Pets, Other): <br />I 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 />n3 <br />C� <br />Certification: <br />1 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 />I must . be present during the sampling event, 9Z <br />I dq agree to participate In the Forward Landfill Domestic Well Sampling Program. <br />Date: <br />