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Ui <br /> STAT OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR Govemor <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 96080 West Sacramento,CA 95691 Fresno,CA 93726 Glendale,CA 91203 <br /> (530)529-7304 (916)376-9612 (559)230-3300 (818)500-1645 ext.233 <br /> i <br /> (530)529-7322(Fax) (916)376-9076(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 stud associated with the unauthorized release,if the study is conducted pursuant to a <br /> c eaP Y <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: _hOCM&riZ7. lFGiC;1►�t1 County: ^San �'Oaqu� jj - <br /> i <br /> Street Address: 7 rFA�� u �Aaef . City: t f aP_y <br /> Township, Range, and Section: _ Radius_: I m;`G ^ <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Requester's Company Regulatory Agency Name <br /> &4- ie u_>ov Hay, I I Y) )61211. <br /> Requester's Name(please print) Agency Contact Name(please print) <br /> IM T f- v Sob boy F Ateb er Avel Ut, 5", noot <br /> Address Address <br /> WaIVIU 4 Cr'-.ek . (: r4gU �� s l(_& �l< C n 9s Z-0 I - o3% <br /> City, State, and Zip Coe City, State, and Zip Code <br /> k <br /> Signature: 4db Signature. . IZ6 �"'[ <br /> Title: 1'fw, to oe o oai' f Title: <br /> Telephone: Telephone: (dos ) (l6 Y-_3 <br /> FAX: ( ) FAX: (?0-7 <br /> Date`{ S-� __ Date: JI2'sI'Vil <br /> E-mail: KGt 1�� � waj-�@_Pg! M, Co M E-mail: �i/Cnlol/C7 STC.t-0t� .G�W� � <br /> I <br /> wcr request_envdeanup_20110518.doc 18 May 2011 <br /> I <br />