Sound Monitor Survey Form

                                            Township                                                                   County

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* Dominant wind direction                             *General wind speed:
*Ambient temperature:                *Humidity:                 *Atmospheric Pressure::          *Weather Conditions:
* check if monitoring indoors    Yes ___
Sound Monitoring Equipment -  Sper Scientific Sound Meter, Model # 840029, Certified Calibration
Sound Monitoring Equipment (other) -
Signature of person conducting survey __________________________________Date: ____________

Any former complaints file?   __ Yes   __ No        If so, to whom? ________________________________

(Company Name      /  Representatives Name)

Well site number (if known)  _____________
Location of nearest crossroads if well number is not known   ___________________________________
Complaintee name & address   

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