Laserfiche WebLink
11 , 11 / 2004 THU 12 : 44 FAX 916 679 2422 URS SACRAMENTO FINANCE Q004 / 007 <br /> STATE OF CALIFORNIA - THE RESOURCES AGENCY GRAY DAMS Govornor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento, CA 05616 Red Bluff, CA 96080 Fresno, CA 93726 Glendale, CA 91203 <br /> (916) 227-7632 (530) 520-7300 (650) 230-3300 (818) 543.4600 <br /> (916) 227-7600(Fax) (530) 529-7322 (Fax) (559) 230.3301 (Fax) (ata) 543.4604 (Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT—AGENCY <br /> (Government and Regulatory Agencies and theirAuthorized Agents) <br /> �jr ,�jI, 4106 N.41r6e la <br /> Project/Contract No. �QC� Tt 116v1 21 D 'j6r14'k4 ,n County. 5cLv- ; t .� <br /> Township, Range, and Section 'J ;2- N G E S t � S l Radius 2,0dd <br /> (Must include entire study area and a map that sho s the area of int <br /> blest) <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 (check one): <br /> Make a study, or, <br /> ❑ Perform an environmental cleanup study associated with an unauthorized release of a <br /> contaminant within a distance of 2 miles. <br /> In accordance with Section 13752, information obtained from these reports shall be kept confidential <br /> and shall 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 Information 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 /> Authorized Agent Government or Regulatory Agena <br /> 2. 25 C� 0e - 300 ��'. tJb <br /> eer Aoe. <br /> Address — T Address <br /> City, State,State, and Zip Code City, State, and Zip Code <br /> Signature Si nature ✓/ ��*^t�icG4� <br /> Title e. ( 05t Titlej6 <br /> Te_tephone 16 ) Gq ZZG I Telephone <br /> Fax ( 1 ( 6 ) 67c Z9t oo Fax Tat X08 3833 <br /> Date I11( /6 ^, Date /Girl/ �S 2oe <br /> E-mail wt`, lC� � ial �JrSCpr � ecw E-mail �' tfttrR � SJC�7ri+- CG1� <br /> 6 June 2001 <br />