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03/28/05 13:36 FAX E.R. I. R002 <br /> D. <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,Govemor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAdUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95816. Red Bluff,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 /> f4 _T4 u'^ <br /> Project/Contract No. 6 Z'y 1 q Z�0 StI V 1J County 4 t1 <br /> Township, Range, and Section 12- N I (L bE , S,c 1� _ Radius ��000 Ff <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 ins pect or copy, or for our authorized agent nam ed below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to (check one): <br /> Make a study, or, <br /> —j Perform an environmental cleanup study associated with an unauthorized release of a <br /> I 1 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 weil(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. 4 <br /> 1C'Vvlroh � I�i�o&b;r SNC . Si-, �A��i r �o. gF £/iIJ <br /> I <br /> Authorized Agent / f D t Government <br /> ,00rr Regulatory Agency <br /> p( Ar1f1 ltd W Gf l b 0 w I PYP.. � �'" • <br /> Address Address �V <br /> A4/it ri guG��ti /�w <br /> City, State, and Zip Code Clty, State, and Zip C <br /> Signature Si natu e <br /> �JV—A.� <br /> Title ;.y(' �IAPP tWyfAct�- Title .56W/B1e <br /> Telephone ( 707) 741 - 2 0 2- Telephone (yl ) <br /> Fax f 70- ) 7921 -- OY/e/ Fax <br /> Date -3/2- 0 S" Date ��S <br /> E-mail W 1`G►1 d erg -u S . C 0 vh E-mail_�� /GEt�`�• C'�l► <br /> 6 June 2001 <br />