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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: '2-5-1412 S v r nN Qd Date: Le 12Cl lt"1 <br />Resident/Owner Name: C arre✓11 <br />Sampling Date/Time: V_I�'LO�\�1 j10� (Estimated sampling time is 15 to 20 minutes) <br />h��iY' tY1 Fr�r'1'l fr�� F rank al - <br />Access Issues (Locks, Animals/Pets, Other): rczr <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 />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, an <br />I must to be present during the sampling event, or <br />do not need to be present during the sampling event. <br />1 do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: 0 "" <br />Print: Intl I C� R RO l <br />Remarks: <br />Field Certification:=4� LIU Date: 2 <br />