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04/14/2002 22:23 FAX Z02 <br /> _�. . ... � rt1� I '227-7600 <br /> RPR '03 14 :57 No -004 P .01 <br /> .STAT!OF CALIFORNIA"THg npe00 CES AGEMCV OR V see <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JpA4U1N DISTRICT 8WT)iERN D157RICT <br /> 3251 S Shap[ 2440 Main Street 3374 Eg51 Shielps Avenue 770 Fairmont Avanua <br /> saCramente, CA 85616 Red Muff, CA 8$080 FreOno,CA 83720 Gendels.CA 91203 <br /> (016)227-7832 (53 5267940 (589)2W-3300 <br /> (816)227-7600(Fsx) (5341,623-7322(Fax) (6591)230-3301 (FAN) ( 16)5434604 <br /> (81 a)549.4604(Fuc) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT-AGENCY <br /> (Government and Regulatory Agencles and their Authorized Agents) <br /> Prolact Contract No. MOM F IO f RR M r [e X A co �771eCounty s A 41 .TDAcQ u !hl <br /> Sal Af6tV. ejtrroktr /aNe� coDr Z-aP-4-/may <br /> Township, Range, and Section I T' Ar rO Eb Radius zJ a� <br /> (M wt IndUtla entire aaury ares arlp a rtw that sh the ales of Irnerost.) <br /> Unoer Callfornia Water Code Section 13762, 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 /> aMake a study, or, .. <br /> ® Perform an environmental cleanup study 919soclated with an unauthorized release of a <br /> contaminantwithin a distance of 2 miles. <br /> In aocordance with $action 13752, Information obtained from these reports shell be kept confidential <br /> and shell not be disseminated, published, or made available for inspection by the public without <br /> written authorization from the owner(s)of the well(s). The informason shall be used only for the <br /> Purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall be <br /> kept in a restricted file accessible only to agency staff or the authorized agent. <br /> nvlroaMpuf� r1t�o/{�l Dep /• <br /> 5-F ked . T7-bAau)Ar COON7-y <br /> Authorized Agent Government or Regulatory Agency <br /> 3oI I��4+FL-e elkee Averv� <br /> Address Address <br /> (NOODSQ I36-ECA 95�25-0 54-crlct`-&' I, ck( gSr202 - 2700 <br /> City, State, and zip Code Ctty, State, and Zip Code <br /> 5)11IV7 <br /> rine 4l' I Aj o f R L _. Tttljj sI <br /> I ho 6 Z� <br /> Telephone (,?DQl '",7(ag - 3q 9 ' - <br /> Fax f 2) 36 - 935 Faxyb8� 3y3 <br /> oat Date <br /> E-mailSC>Mv12 vl� �ar/(�f. +lr,�e� ei cA01/ s I 1I <br /> - .. tl { CC.�pe rnorv) <br /> 6 June 2001 <br />