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D • • + PROGRAM <br />N%—Ie WELL ACCESS SHEET <br />Address: Date: <br />Resident/Owner Name: <br />Sampling Datefime `f (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, purpose): <br />is, I '.Fi'ij1'JijijjFi mom= <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 />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, ar <br />must to be present during the sampling event, nLr <br />o <br />I 9need to be present during the sampling event. <br />I dR agree to participate In the Forward Landfill Domestic Well Sampling Program, <br />Signature: <br />Print: <br />Remarks <br />field Certification: Date: <br />