Laserfiche WebLink
-OCT.26.2005 7:34AM APWNVIROTECH,INC. NO.948 P.2 <br /> • <br /> $TATE OF CALIFORNI THE RESODRCES AGENCY ARNOLD SCHWAp7ENEGGER Gavemor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95816 Red Bluff,CA 95080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)227-7632 (530)529.7300 (559)230-3300 ( ) <br /> 543-4600 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230.3301 (Fax) (818)543-0604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT—AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract No. County <br /> Township, Range, and Section Radius <br /> (Must induce entire study area a. 9d a map that shows the area of interest.) <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 (check one): <br /> ZIMake a study,or. <br /> F7Perform an environmental cleanup study associated with an unauthorized release of a <br /> contaminant within a distance of 2 miles. <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 public <br /> without written authorization from the owner(s)of the well(s), The information shall be used only for <br /> the purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall <br /> be kept in a restricted file accessible only to agency staff or the authorized agent. <br /> ex ra4e-e& 1A& C- <br /> Authrized Plgent Govemment or Regulatory Agency <br /> !MLI 1 U1 ?FDy � 1 1 F �P✓ /pct . �r� F(cx�r` <br /> Address Address <br /> 7ol',�j ALB R 56�7tq �� 0,A 95wz- <br /> City, State, and Zip Code City, State, and Zip Code <br /> 5i natu Ll Si nature <br /> T' le Title <br /> Telephone R*) R5 f-017 Telephorle6M) Og y✓ 1 s <br /> Fax (910) Eca I —0 $ ( Fax ql q- <br /> Date_�O/��S Date l6 <br /> CUA <br /> E mail 1tiVl l �aytr�ICG�,ra>» E mail �/✓�'�'y <br /> 6 June 2001 <br />