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,4TATE OF CALIFORNIA-THE RESOURCES AGENCY ARN LD CHWARZENE ERgovernor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 901 P Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95814 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)651-0753 (530)529-7300 (559)230-3300 <br /> Fax <br /> 233 <br /> (916)651-0726(Fax) (530)529-7322(Fax) (559)230-3301 (818)500-1645 ext. <br /> (Fax) (818)5434604(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, if 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 DWR 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: kv11n Sulu` 3d(� � ( County: Sc.1 �'gn�`11� <br /> LIZ Street Address: Z 17 )At h r p} -rA„& City: % -A (C _ to <br /> M.L' Q,0-61,D k,-c.rnd.C,..., <br /> Township, Range and Section:i i u 2 (� C St5:7L Radius: A,:4,L <br /> (Include entire study area and <br /> ^a_map that shows a area of interest.) �r /' �^ (maximu/m'2 miles) /� y1, <br /> FA)� c2 rt(r`� j0. .�lAsm� w l.G. I�NYIt�. 14.,11•L nt01 <br /> Requester's Compa4y Regulatory Agency Name <br /> VLTG6Eal4 t-Suf,,� LIL,40r•t0 <br /> Requester'14Name (pleas print) 5 inti(fid Agen Contact Na (please print) <br /> 104L( O (A (P(4L, rut, 1t-r, R_ 3G4E. 110 .r � , 3rdh'( r <br /> Address Address <br /> �- <br /> CA 9 $ ��krw r A C tang: <br /> City, State, and Zip Code City, State, and Zip Code <br /> Si nature: Si nature: <br /> Title: ( Title: p per. WO/ <br /> Telephone: (Ql6) 3 bD X Cl I Telephone: L�W-3cf L(q <br /> FAX: (%c') FAX: (meq ) LI/of - 3 q-3 3 <br /> Date: yZ-� Y�t� Date: 67 <br /> E-mail: ogQr<1nlLISC G1?Com-CW4 E-mail: 1/t�(Q�,af rc�Q� SS N� <br /> wcr request-envcleanup_20060706.doc 07 July 2006 <br />