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FROM Geo-Phase Environmental ' FAX NO. : 2095690295 -Jan. 17 2006 11:12RM P2 <br /> %W1 %-4 <br /> STATE OF CALIFORNIA-THE RESgURCES AGENCY ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL,DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHURN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95815 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (915)227.7632 (530)529-7300 (559)230-3300 (818)543-4e00 <br /> (a IS)227.7600(Fax) (530)529-7322(Fax) (559)230-3301(Fax) (818)543-4604(rax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> ProjecVContract No. ae-w S County S;P-4 JA4�pv/" <br /> If <br /> Township, Range, and Section 1_� 'c� fee- I _Radius O[70 <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 tiled pursuant to Section 13751 to(check one): <br /> ElMake a study, or, <br /> 5 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 /> Authorized Agent Governm or gulatory Agency <br /> Address Address <br /> 4r7V fxf _ fir .Gb '7 S J 62— <br /> City, <br /> ZCity, State, and Zip Code City, State, and Zip Code <br /> Signature Si nature k <br /> M_-P_q <br /> Title � Title �t�S <br /> Telephone iR?F) 5RW ARf-3 Telephone Q6A <br /> Fax 91- 462 S Fax 6 L YTY <br /> Date :Z7 /4 ©ate 14 110� <br /> Z <br /> E-mail Ze-k AW-7r 01AC? ^lfe7.CG-XI E-mail rJo�l cov.- <br /> 6 June 2001 <br />