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• <br />0 <br />DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br />WELL ACCESS SHEET <br />Address: S-1 I Z Sv n n -A Q.c, g�'d Date: to i G�-1 <br />Resident/Owner Name: At ieA>n M r,s ria <br />Sampling Date/Time: lr r,a 11,1 lu tS (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): i <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 />7-11 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 />O I must to be present during the sampling event, or <br />I do not need to be present during the sampling event. <br />QI do not agree to participate in the Forward Landfill Domestic Well Sampling Program. <br />Signature: <br />Print: <br />Remarks <br />Field Certification: Date: <br />