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.............. <br /> i <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,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 96080 West Sacramento,CA 95691 Fresno,CA 93726 Glendale,CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230-3300 (818)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: CCT S fcxk fon Re IYa 0 Counter: <br /> Street Address: &y S- J ergo j,,ep Lar`y_ City: S kr.kton <br /> Township, Range, and Section: Radius: 16 rile <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> -Tk Scan zaa�uin uimly Ghy{ron",tA}cl1 1441A ew-i. <br /> Requester's Company Regulatory Agency Name -1 <br /> lift S F1 N 90jeN L-Of'l D v�AN <br /> Requester's Name(please print) Agency Contact Name(please print) <br /> 1596 Soir.,t o WG,y #A 6W E. IUiG rn 54CV44- <br /> Address Address <br /> Co ,L,rul, C.A 94520 %Jef-an,cA 95ay:). <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: �/ Y Signature: C ►� fc�_ <br /> Title: &n Cc r $f��� S���n i.s>I Title: cSe4-t%_0j (ZEHS <br /> Telephone: ( q1S) 6 ggg-a fu 3 Telephone: (Z(A( ) t(�jg o33 <br /> FAX: FAX: ) <br /> Date: Date: <br /> E-mail: !��INe+Q;trr.5nl�j r�S,t,o�, E-mail: <br /> wcr request_envcleanup_20090928.doc 28 September <br /> 2009 <br />