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FROM Geo—Phase Environmental FAX NO. : 2095690295 Jan. 17 2006 11:13AM P3 <br /> V-01 I%=,, <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGE Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95x16 Red Sluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230-3300 (818)543-4600 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230.3301 (Fax) (818)543-4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract Nogg' ,!/Q'�Y,G'i^. 0 STa�lsT�w^ County + 447-701/• <br /> Township, Range, and Section //Jt -57&a �C Radius ,Zpr �'-- <br /> (Must include entire study area and a map that shows the area of interest.) <br /> Under California Water Code Section 13752, the agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for our authorized agent named below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to (check one).. <br /> Make a study, or, <br /> Perform an environmental cleanup study associated with an unauthorized release of a <br /> contaminant within a distance of 2 miles. <br /> In accordance with Section 13752, information obtained from these reports shall be kept <br /> confidential and shall not be disseminated, published, or made available for inspection by the public <br /> without written authorization from the owner(s)of the well(s). The information shall be used only for <br /> the purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall <br /> be kept in a restricted file accessible only to agency staff or the authorized agent', <br /> �r24/�kaj e' , �+4ylr'Q7J�tP^r?t?� , �L S4 A/ T1� ` U• /i <br /> Authorized Agent Governmen r Re latory Agency <br /> ;2 93,7 (� -+�z° Q�_ ,( �D '5d 7 C P,✓����1� <br /> Address Address <br /> City, State, and Zip Code City, State, and Zip Cod/ems _ <br /> Si natur � Signature km-4 �C/0 <br /> Title /zk4i!�"7— Title R�614y <br /> Telephone (,10?) 5�9 f�,�2 9� Teleohone 0M) <br /> Faxes 7, 61 �9 ©.Z9 Fax f Y 6 (Y <br /> Date �6�,�G Date l b p(' <br /> E-mail /2 E-mail <br /> 5da1'I!�r t}C <br /> 0� <br /> 6 June 2001 <br />