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STATE OF CALIFORNIA THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR.Governor <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 /> (53)529-7322(Fax) (916)376-9676(Fax) (559) 33 <br /> 230-3301 (Fax) (818)543-4604(Fax00 (a18)500-1646 ext.) <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: 6 P s r County: Su So a a •� <br /> Street Address G Ir90 N N u, q `1 City: Sac {,r <br /> Township Range and Section: 12N, 9_7E Sec It Radius: `Z,Vo o <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> AR G A D.T S T«il�iin v�v�1c/ mac/ , <br /> Requester's Company Regulatory <br /> Agency Name <br /> S(GVC1< I l✓(4� / ��+ r � Y <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Address Address <br /> rots. 6!4 9S-63o rZ %0t)�5 <br /> City, State, and Zip <br /> //Code City, State, and Zip Code <br /> Signature: L Q !off Sin ature: <br /> Title: 6e o l o�,XE Title: <br /> Telephone: ( q1 ) 981"' -2c -7R x 13 Telephone: (may) yam`-3S'S�i <br /> FAX: ( 116 ) 19S- 20ti3 FAX: (a0Y) <br /> Date: y2�6 A3 Date: <br /> E-mail: ;Lcvete. naw{ G ti(cFd s -us•Lon E-mail: <br /> wcr—request_envcleanup-20110518.doc �'� ���j�� �_ 18 May 2011 <br />