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STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E.Shields Ave Ste A7 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)500-1645 ext.233 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)543-4604(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 /> Project Name: Pacific Auto Center County: San Joaquin <br /> Street Address: 25355 Highway 99 City: Acampo <br /> Township Range and Section: T4N R6E 1 & 12 Radius: 1 mile <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Environmental Resolutions, Inc San Joaquin County Env. Health Dep. <br /> Requester's Company Regulatory Agency Name <br /> Travis Finn ViG{-oria L . MC Car+ney <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 601 North McDowell Boulevard 600 Eas+ .Main S+ree- <br /> Address Address <br /> Petaluma, California, 94954 Stockton 'California 95202- 3029 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: Signature: Vf� <br /> Title: Assistant Project Manager Title: Senior REHS LOP/Site Mit . Uniti <br /> Telephone: (707 ) 338-8016 Telephone: ( 209 ) 468-9852 <br /> FAX: ( 916 ) 543-1379 FAX ( 209 ) 468- 3433 <br /> Date: August 14 , 2007 Date: August 1$, 2007 <br /> E-mail: tfinn@eri-us .com E-mail: vmccartney@sicehd.com <br /> wcr request-envcleanup_20060426.doc 26 April 2006 <br />