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' Jul. 18. 2005 3: 31PM V inced GeoEnvironmental No- 1349 P. 2/2 <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor <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 95816 Red Sluff,CA 96080 Fresno, CA 93726 Glendale, CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230.3300 (816)543.4600 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230.3301 (Fax) (818)543-4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract No. ` S - °141 ( 5��, moa <br /> � <br /> NO)P' 71rlw f0�e f'�-�P.L T- nn. <br /> I IK� FS�ASeG. -3I 11 <br /> Township, Range, and Section 'Ti r JZHE, sz 0. 2�U©n -- �oa� Radius <br /> 'n N, f4 q E-, 5�, 2S <br /> (Must include entire study area and a map that shows the area of interest.) <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 authorised agent named below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to (check one); <br /> 1-1 Make a study, or, <br /> erform 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 <br /> confidential and shall not be disseminated, published, or made available for inspection by the public <br /> without written authorization from the owner(s) of the well(s). The information shall be used only for <br /> the purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall <br /> be kept in a restricted file accessible only to agency staff or the authorized agent. <br /> &Jrlrtf.pt) 50 AVO..ft 0_�1.AV�T:f <br /> Authorized Agent v,a1 Government or Regulatory Agency <br /> r✓V\v%r'o H wN ew{m.( t-ka c-1'l, <br /> ���1 S► w �o.� 1J erDu v t w\tV%A— <br /> Address Address L W-e (�e V lvv-f <br /> S 40dr- -o� C A- 9 5-2-o Z <br /> S�1.1�.�1) , Gil asxt�--- <br /> City, State, and Zip Cade City, State, and Zip Code <br /> Si nature Signature (_0" Gt { <br /> Title S}��� �eo �og�st Title Seatvy (ZE 14;S <br /> Telephone t00Cn--__ Telephone (cWj <br /> Fax (Z©J) if G7 HP;I d Fax L_Ao-() <br /> Date 01 - I g 0!!��_ Date -�( C1 (C S- <br /> E-mail <br /> E-mail E-mail or� e �co <br /> 6 June 2001 <br />