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14 <br /> AP r. 30• 2001 4: 15PM ATC ROUP SERVICES INC. <br /> No. u3yv Y <br /> �1j�r✓ Ci.ryyAR2ENEGGER Gova o <br /> F RNU1-THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT 3374 E. Shields Ave Ste A7 770 Fairmont AvenueN JOAQUIN DISTRICT SOUTHERN lDISTRICT <br /> 3251 S Street 2440 Main Street Glendale,CA 91203 <br /> Sacramento,CA 95616 Red Bluff,CA 96080 Fresno, CA 93728 (818)500--14 04 ext. <br /> t)33 <br /> (916)227.7632 (530)529-7300 (559)230-3300 <br /> (916)227.7600(Fax) (530)529-7322(Fax) (559)2303301 (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 requestto 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 tWater Code Section 13752). <br /> o the Requests must be made on the form below, signed and submitted <br /> the study as for berlconduate Wcted. IAttach Oa map or Please <br /> provide the township, range, and section of the <br /> property <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. -r <br /> Project Name:JA MAY YVM tiion JC <br /> County: Sam A �19� <br /> Street Address <br /> 015 1 olmt Maim Sy City. Sto cK�ro� <br /> Ems') Radius: a- VY11k� <br /> Township, Range and Section I t� /"1 (maximum 2 miles) <br /> (Include entire study area and a map that shows the area of interest.) <br /> ATC <br /> 8S C I .,,( Name <br /> nrintoc ctv���Irx,ar)' <br /> Regulatory Agency Name <br /> Requester's Company <br /> Amber Mihaml L10 DUA)C(4/ ) <br /> Requester's Name (please print) Agency Contact Name (please pant) <br /> jj�j j,pje Po►lm five, Svute 201 Ad CO E YOA1nl �T <br /> Address <br /> m0des�o Col X351 SIVCLo �T /V c szoz - <br /> City, State, an ode City, State, and Ziip Code <br /> Si nature: Ol,*., � Signature <br /> r� Title S ^� r2 c U-S <br /> Title S1QlE� GeOlo�►Sfi <br /> Telephone 201) 6101 • 222 <br /> Telephone: 16 9`0�� <br /> (2Dq) S�I oI-t 2 22 5 FAX (ao9) <br /> FAX N6 �3 3 <br /> Date ��'3D ' 1 Date S <br /> E-mail: 0l <br /> vAbey. mlrnami 01t(ASSOLIAWS. OrhEmaiP �r� ol. l,rnw <br />