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• 0 <br /> STATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NORTH CENTRAL REGION SOUTH CENTRAL REGION SOUTHERN REGION <br /> 2440 Main Street 3500 Industrial Blvd. 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Red Bluff,CA 96080 West Sacramento, CA 95691 Fresno;CA 93726 Glendale,CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230.3300 (818)500-1645 ext.233 <br /> (530)529-7322(Fax) (916)376-9676(Fax) (559)230-3301(Fax) (818)543-4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT—AGENCY STUDY <br /> (Government Agencies and their Authorized Agents) <br /> Under California Water Code Section 13752, the agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for our authorized agent named below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to make a study. <br /> In accordance with Section 13752, information obtained from these reports shall be kept <br /> confidential and shall not be disseminated, published, or made available for inspection by the <br /> public. The information shall be used only for the purpose of conducting the study. Copies <br /> obtained shall be stamped CONFIDENTIAL and shall be kept in a restricted file accessible only to <br /> agency staff or the authorized agent for this study. t <br /> Project Name: AKCC0 Se�ryit-c StAfttj,�n Yo y q! 1 32 County: Stin �aagV)Yi <br /> Street Address: 1b Las+ P4r�t(i1i to/gay City: StOc-k-+-0 <br /> Township, Range, and Section: Parc t Ntao Ap 7 +J10 oo ^� rL <br /> A�¢-t4 tqCc1 Radius: <br /> (Include entire study area and a.map that shows the area of interest.) // <br /> 5hnrec CDnsv'l41n 5el-Victs T �'ne- ]An oau,.in 1.0vyt V._�1-nVjrOh*MC/+�'41 <br /> Authorized Agent Company Name Government AgLfncy Name #jca it De PQy t✓w ent <br /> 'bD17 K;15oreRid 5uife- JoD boo E_41S - MAW% '3+17- eC <br /> Address Address <br /> kg.y%c1,0 Gerdove,> CA X500 SitOC.t--+oh , CA <br /> City, State, and Zip Code City, State, and Zip�Code <br /> 1. 4.1)-%C.r}yx e- Fra,,, / r <br /> l n _ MfKe Tn YL)r nck <br /> Authorized Agent Name(please print) Agency Contact Nam lease rint) <br /> Signature: j(�y>G,� Si nature. <br /> Tilde: 1Y-01Cc ahacr- Title: t�e�i5-�tred Environrnenf"9) Pearl <br /> %� <br /> 5pccl+a�15�' <br /> Telephone: (% ) $61- O�OO Telephone: (a �!o t6$' �JLJSy <br /> FAXtIlb ) Al- QJ 30 FAX: (d01 )) `iby - 013�' <br /> Date: i t 11 IR Date: 1 / it / 1 a <br /> E-mail: , � Y'106lrllnw E-mail: 111xY\f%jYr\a[a, $ ICC,.�1a C-oa�} <br /> 5fi6,n ec eon <br /> wcr_request_agencystudy_20110518.doc 18 May 2011 <br />