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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 96060 West Sacramento,GA 95691 Fresno,CA 93726 Glendale,CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230-3300 (618)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: Stockton Arena Hotel&Cn <br /> onferece Center,LLC <br /> 1 , _ County: San Joaquin <br /> Street Address: 423 N Madison Street City: Stockton <br /> Township, Range, and Section:tLIA , ,s-ee— ,,i de Imgy} Radius: -,7__005 f",-� <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Treadwell & Rollo, Inc., a Langan Company San Joaquin County Department Env. Health <br /> Requester's Company Regulatory Agency Name <br /> Jeremy C. Gekov, PG Lisa Medina, RENS <br /> Requester's Name(please print) Agency Contact Name(please print) <br /> 501 14th St, Third Floor Td <br /> Address Address <br /> Oakland, CA 94612 Stockton, CA 952W5 <br /> City, State, and Zip Code City, Stat and Zip ode <br /> Signature: Si I ature- <br /> Title: P ect G logist Title: <br /> Telephone: 510 874-7027 Telephone: (�) <br /> FAX: ( 510 ) 874-7000 FAX: <br /> Date: 10/17/12 Date: <br /> E-mail: jgekov@langan.com E-mail: �irx��/ C ? /CPsyc� <br /> wet request envcleanup_20110518.doc 1 B May 2011 <br />