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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 REQUEST AND CONFIDENTIALITY AGREEMENT <br /> REGULATORY-RELATED ENVIRONMENTAL CLEANUP STUDY <br /> Well Completion Reports associated with wells located within two miles of an area affected or potentially affected <br /> by a known unauthorized release of a contaminant will be made available upon request to any person performing <br /> an environmental cleanup study associated with the unauthorized release, if the study is conducted pursuant to a <br /> regulatory agency order[;Water Code Section 13752). <br /> Requests must be made on the form below, signed and submitted to the appropriate DWR District Office. Please <br /> provide the township, range, and section of the property where the study is to be conducted. Attach a map or a <br /> sketch with a north arrow, and provide as much identifying information requested below as possible;-additional <br /> paper may be attached if necessary. <br /> By signing below, the requester acknowledges and agrees that, in compliance with Section 13752, the <br /> information obtained from these reports will be kept confidential and will not be disseminated, published, or <br /> made available for inspection by the public. Copies obtained must be stamped CONFIDENTIAL and kept in a <br /> restricted file accessible only to authorized personnel. These reports must not be used for any purpose other <br /> than for the purpose of conducting the environmental cleanup study. <br /> Project Name: <br /> Chevron#94257 and ARCO 2133 Commingled Plume County: San Joaquin <br /> Street Address: 2905 and 2908 West Benjamin Holt Drive City: Stockton,California 95207 <br /> Township, Range, and Section: Radius: 2,000 feet <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Stantec Consulting Services Inc. San Joaquin County Environmental Health Department <br /> Requester's Company Regulatory Agency Name <br /> Brian Westhoff, P.G. Ms. Lori Duncan <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 3017 Kilgore Road, Suite 100 600 East Main Street <br /> Address Address <br /> Rancho Cordova, CA 95670 Stockton,California 95202 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: Signature: <br /> Title: Senior Geologist Title: Senior REHS <br /> Telephone: ( ) Telephone: ( 20°( ) V6 K-033 �- <br /> FAX: ( ) FAX: ( ) <br /> Date: Date: <br /> E-mail: E-mail: (Ju r, eru®Srd G J -cm Wt <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br />