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STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,Governor DEPARTMENT OF WATER RESOURCES NORTHERN REGION NORTH-CENTRAL REGION SOUTH-CENTRAL REGION SOUTHERN REGION 2440 Main Street 3500 Industrial Blvd. 3374 E.Shields Ave Ste A7 770 Fairmont Avenue Red Bluff,CA 96080 West Sacramento,CA 95691 Fresno,CA 93726 Glendale,CA 91203 (530)529-7300 (916)376-9612 (559)230-3300 (818)500-1645 ext.233 (530)529-7322(Fax) (916)376-9676(Fax) (559)230-3301 (Fax) (818)543-4604(Fax) WELL COMPLETION REPORT RELEASE REQUEST AND CONFIDENTIALITY AGREEMENT REGULATORY-RELATED ENVIRONMENTAL CLEANUP STUDY Well Completion Reports associated with wells located within two miles of an area affected or potentially affected by a known unauthorized release of a contaminant will be made available upon request to any person performing an environmental cleanup study associated with the unauthorized release, if the study is conducted pursuant to a regulatory agency order iWater Code Section 13752). Requests must be made on the form below, signed and submitted to the appropriate DWR District Office. Please provide the township, range,and section of the property where the study is to be conducted. Attach a map or a sketch with a north arrow, and provide as much identifying information requested below as possible;-additional paper may be attached if necessary. By signing below, the requester acknowledges and agrees that, in compliance with Section 13752, the information obtained from these reports will be kept confidential and will not be disseminated, published,or made available for inspection by the public. Copies obtained must be stamped CONFIDENTIAL.and kept in a restricted file accessible only to authorized personnel. These reports must not be used for any purpose other than for the purpose of conducting the environmental cleanup study. Project Name: S—rc>cL4---tt=>r. Sc AJF--jasr.2, County: SA--) Son�Qvl� Street Address: I Zd.a N AJ Y C)-2I.ItF— City: S-roCu,C-Zc� Township, Range, and Section: Radius: (include entire study area and a map that shows the area of interest.) t (maximum 2 miles) l I C.;'t." Jam.,^ J oa, `r ^� CC � F�'L Requester's Company Regulatory Agency Name Requester's Name (please print) Agency Contact Name (please print) Address q 5-�,)Z-7 Address City, State, and Zip : ode City, State, a d Zip Code Si nature: s Si nature Title: 5-e- P-z--tti c.-C Title: �f Telephone: (1-1 t6 ) 3 6 z Telephone: ( T.vcl ) 46 E 14Q,—" FAX: { ct t6) 3 6 Z— V(oL-> FAX: `? 4-r,F- 34.3 Date: I d - 2 -7-OC/ Date: /O Z 7 --d y E-mail: 1~+'..dc •c5-('as (9L ae-CL'T_cc- E-mail: ID S1�c��-c wcr request envdeanup_20090928.doc 28 September 2009