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STATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR,Governo_r_ <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)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(Water 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 /> Shockey and Sons Trucking San Joaquin <br /> Project Name: T _ County: <br /> Street Address: 850 Milgeo Avenue City: Ripon <br /> Section 19 Township 2 South Range 8 East 2,000 foot <br /> Township, Ran e, and Section: Radius: <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Advanced GeoEnvironmental San Joaquin County Environmental Health Department <br /> Requester's Company Regulatory Agency Name <br /> Daniel Villanueva Harlin Knoll <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 837 Shaw Road 600 East Main Street <br /> Address Address <br /> Stockton, CA, 95215 Stockton, CA, 95202 <br /> City, State, and Zip Code City, State, and Zip Code a <br /> Signatur . Signature: <br /> Title: Staff Geologist Title: Senior Registered Environmental Health Specialist <br /> Telephone: { 209 ) 467-1006 Telephone: ( 209 ) 468-3442 <br /> FAX: ( 209 1 467-1118 FAX: 209 468-3420 <br /> Date: 07/15/2011 Date: <br /> dvillanuevapadvgeoenv.com hknoll@sjcehd.com <br /> E-mail: E-mail: <br /> wer_request_envcleanup_20110518.doc 18 May 2011 <br />