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MAR-30-1996 22:47 P.02/03 <br /> STATS OF CAUFORNIA-THE RESOURCE§AGENCY AgNOLD SCHWARMEGGE& <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95816 Red Bluff,CA 96080 Fresno,CA 83726 Glendale,CA 91203 <br /> (916)227-7632 (530)528-7300 (559)230-3300 (818)500-1645 ext.233 <br /> (816)227-7600(Fax) (530)529-7322(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, it the study is conducted pursuant to a <br /> regulatory agency order jWater Code Section 13752). <br /> Requests must be made on the form below,signed and submitted to the appropriate QWR 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; Ctfi�'1l P-skl q-1' 2 - Coun :5PcN <br /> Street Address: k1t,1 SjpgoEr City: 12-0-PC>r" <br /> Townshi , Range, and Section: TSSP !� <br /> Radius: <br /> 9- <br /> (include entire study area and a map that shows the area of interest.) (maximum 2 miles) 1� <br /> U QJXv ft7.r I �A44:LO&ULL►NEA1%n cat LAl y <br /> Requester's Company Regulatory Agency Name <br /> 1Zou <br /> Requester's Name(please print) Agency Contact Name(please print) <br /> 0 NI <br /> Address Address / <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: 70 Signature: <br /> Title: C7L4� Title: H S. <br /> Telephone: 1(t 6-11 - 3 Telephone: <br /> FAX: q 1 V ) FAX: 201 41Q <br /> Date: ( 1� Q�- • Date: / 2-3 0 7 - <br /> E-mail: rf_pjA tSC�? -awtbvia~ eAV. LQaO E-mail: 4maearinevO iceAd COM <br /> wcr request-snvdsanup_20060426.doc 26 April 2006 <br />