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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 96080 West Sacramento, CA 95691 Fresno, CA 93726 Glendale, CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230-3300 <br /> Fax <br /> 233 <br /> (530)529-7322(Fax) (916)376-9676(Fax) (559)230-3301 (818)500-1645 ext. <br /> (Fax) (818)543-4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT—AGENCY STUDY <br /> (Government Agencies and their Authorized Agents) <br /> Under California Water Code Section 13752, 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 filed pursuant to Section 13751 to make a study. <br /> In accordance with Section 13752, information obtained from these reports shall be kept <br /> confidential and shall not be disseminated, published, or made available for inspection by the <br /> public. The information shall be used only for the purpose of conducting the study. Copies <br /> obtained shall be stamped CONFIDENTIAL and shall be kept in a restricted file accessible only to <br /> agency staff or the authorized agent for this study. <br /> Project Name: Uc Ul -,1-�r'.-t �, �w� <br /> `` �P/✓iu2 5 County: �1 TD�C�vi✓l <br /> Street Address: 0051 50A P� Drao 51._/1 City: 5000V,00V, <br /> ' <br /> Township; Range, and Section. Radius: 1Z M14 <br /> (Include entire study area and a map that shoves the area of interest.) <br /> 5t(k�5 E / <br /> hvtrvn�� � t ave JdR v.n you Fn r/i2n� <br /> Authorized Agent Company Name Government A ncy Name <br /> 3330 (ag\F/m P j Dr, -it SSo (_��$ � (�qZ&,I l ,'. <br /> Address Address <br /> calm ftL P&Jc) C7AI, 5/17J- ( L 1 <br /> City. Sta e, and Zip de City, State, and Ip Code <br /> Authorized Agent Name (please print) Agency Contact Name (please print) <br /> Signature'. - Si nature. <br /> Title: (�/D Title: <br /> Telephone: (53b) 0_C)& Telephone: <br /> FAX: (S30) (.-7 FAX: ( ;01 <br /> Date: 1 Date: <br /> E-mail: s�i �in y�/�SIY��uS,n(,nG� E-mail: t) IS I S ICCh c up-ki <br /> wcr request_agencystudy_20110518.doc 18 Mav 2011 <br />