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0 0 <br /> STATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR.Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NORTH CENTRAL REGION SOUTH CENTRAL REGION SOUTHERN REGION <br /> 2440 Main Street 3500 Industrial Blvd. 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Red Bluff,CA 96080 West Sacramento,CA 95691 Fresno,CA 93726 Glendale,CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230-3300 (818)500-1645 ext.233 <br /> (530)529-7322(Fax) (916)376-9676(Fax) (559)230-3301 (Fax) (818)543,1604(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 SWater 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 B 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 <br /> gtthe <br /> [environmental cleanup study. <br /> Project Name: ap'rM i//e L4 '30015 County: 1 oa s <br /> Street Address: 'Z 37 L%( A er Azq-e City: 150e /,�vt <br /> Township Range, and Section: AM& 13y 2,(a 17 Radius: ®, 5 044 <br /> (Include y ®® <br /> entire study area and a map that <br /> shows the area of interest.) (ma)imum 2/miles) <br /> /T/' / <br /> P�1f5 a—� , IHe. CJ;eaiti Cocwri`1 L �� <br /> Requester's <br /> '(� - Regulatory Agencyy t/eJr's Companya/me <br /> WttolbA <br /> Requessttees Name(please print) Agency Contact Name(please print) <br /> IJ ��nn p1) fin . JrG f25 ' E Z5>04 � .ems <br /> Address /1 Address <br /> City, State, and ZipCCode City, State, d Zip e <br /> Signature: // Bial � r?Lh Signal re: <br /> Title: Eyy;ravt.rr a/ GP __Sfi Title: i�ir ��sirrr FiaHr�rra> / lf�ir/1 <br /> Telephone: (1(& 2079 Jc 2A Telephone: <br /> FAX: (J/G 985 2093 FAX: (abs) y�P 03f�J <br /> Date: 62 Date: 51 �a <br /> E-mail: wc vty-,q /E-mail: Lqk n <br /> / $ll P co-r <br /> wcr_request_enveleanup_20110518.doc 18 May 2011 <br />