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DOMESTIC/MUNICIPAL WELL SAMPUNG PROGRAM <br />WELL ACCESS SHEET 11111 <br />ress: Date: 4�1 Z) <br />dent/Owner Name: <br />ipling Date/Time; (Estimated sampling time Is 15 to 20 minutes) <br />z�ss issues (Locks, Animals/Pets, other): — —011, <br />Ackno 1 <br />I agree to partidpate in the Forward Landfill Domestic Well Sampling Program and ith <br />ori <br />uthorize sampling of my well at no cost to me. I understand that I will be provided wl <br />a report with the sample results when they are available. Additional sampling may =ur <br />emiannually, and <br />I must to be present during the sampling event, Rr <br />I do not need to be present during the sampling event. <br />c Well Sampling-� - <br />WoM <br />N <br />limn <br />