Laserfiche WebLink
STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWAEggNEGGER,Govemor <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 96080 Fresno,CA 93726 Glendale, CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230-3300 (818)543-4600 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)543-4504(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract No. %'V\ p( <br /> , c, TrU[.L1� Adorn County <br /> Township, Range, and Section Radius <br /> (Must include entire study area and 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 /> Make <br /> ne):Make a study, or, <br /> Perform 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 /> "h Xs1E' ,l.etli•C{u+1me.".'O <br /> Authorized Agent Government or Regulatory Agency <br /> Address Address <br /> City, State, an i /'Code City, State, and Zip Code <br /> Signature/ Si natur / <br /> Title A, C �nz� Titled <br /> Telephone (�u't } �{ 7 1 C:�)' Telephone <br /> Fax QOA } 96- 118 Fax (,hZ <br /> Date ,2 " 7 -,2 Date d ' <br /> E-mail lie- ,Lv JVD« e"'V . L-Co'\ E-mail OG 44,--- <br /> 6 June 2001 <br />