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• DOMESTIC/MUNICIPAL WELL SAMPLING PROGRAM <br /> WELL ACCESS SHEET <br /> Address: 3aa� C11— .rho 5a Q-� Date: b - (9- �0 7 <br /> Resident/Owner Name: <br /> Sampling Date/Time: i 1 12 2 (Estimated sampling time is 15 to 20 minutes) <br /> Access Issues(Locks,Animals/Pets,Other): A,10 Ale <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,and <br /> I must to be present during the sampling event,or <br /> Q I 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: <br /> Print: m-er d <br /> Remarks <br /> Field Certification: Date: / <br /> • <br />