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[null,"This report must be completed and submitted with laboratory reports to the District at the address shown as required by your permit."]
[null,"Consumptive Use Permit Number:"]
[]
[null,"Permittee Name:"]
[]
[null,"Project Name:"]
[]
[null,"FDOH Laboratory ID:"]
[null,"(if applicable)",null,null,"Parameter",null,"Parameter",null,"Parameter",null,"Parameter",null,"Parameter"]
[null,"Well/Pump/Station District ID","Well/Pump/Station Name"," Sample Collection Date & Time ","Name:",null,"Name:",null,"Name:",null,"Name:",null,"Name:"]
[{"$nulls":4},"Units:",null,"Units:",null,"Units:",null,"Units:",null,"Units:"]
[{"$nulls":4},"Method:",null,"Method:",null,"Method:",null,"Method:",null,"Method:"]
[{"$nulls":4},"Result (value)","Lab Remarks","Result (value)","Lab Remarks","Result (value)","Lab Remarks","Result (value)","Lab Remarks","Result (value)","Lab Remarks"]
{"$rows_empty":10}
[null,"I certify that to the best of my knowledge and belief all of the information on this form is correct."]
[null,"I understand that making any material false statement on this form or in any attachments to it may",{"$nulls":5},"Comments:"]
[null,"result in revocation, in whole or in part, of the permit."]
[null,"Name of Person Submitting Data: _____________________________________________"]
[null,"Date: _________________________",null,"Phone Number: _____________________"]
[null,"Email Address: _______________________________________________________________"]
[]
["Form 40C-2.900(11), effective August 14, 2014"]
["Incorporated by reference in rule 40C-2.900(11), F.A.C."]