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4 STATE OF CALIFORNIA-THI=RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E.Shields Ave Ste A7 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)500-1645 ext.233 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230.3301 (F2x) (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 ba 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: �s,C--:--APZA LzE County:__�,At5 <br /> Street Address: � J. . (., fJr�? T City: <br /> Township, Range, and Section: DI —EL t Ij Radius: <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> F__-L1 C_ ��1,1,; NE F.�?VG �r�+� >s)i N �i try Fj3V <br /> Requester's Company . Regulatory Agency Name <br /> PET tfk4- IMP- r��, ..�a ���� REHs <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Address Address ' <br /> City, State, and Zip Code City, State, and Code <br /> Signature ru� Signature <br /> y <br /> Title: -.!;TA El- GED Cn rte-[ Title: ..leirt-r&C 15 Jr6T/ <br /> Telephone: (q25 ) (��Z 5 b x. � Telephone: <br /> FAX: {GzS ) (�o Z— L) FAX: <br /> Date: ��-I /C)6 Date: <br /> �o <br /> r <br /> E-mail: UPJ La, Lar) CD TV-) E-mail: `-_�j[ <br /> I <br /> wer request-envc1eanup_20060426.doe 26 April 2006 <br /> J <br />