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STATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR,Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NURTH 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 /> (530)529-7300 (916)376-9612 (559)230-3300 (818)500-1645 ext.233 <br /> (530)529-7322(Fax) (916)376-9676(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: Q f s-`1 S"- County: o C,9 �. <br /> Street Address: G I ^o N N 6.j 619 City: StLa c f <br /> Township, Range, and Section: T?-A), 9_7E, Sec 18 Radius: 2, Ff <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> AR CA 01 S <br /> Requester's Company Regulatory Agency Name <br /> S1ave1, PC,wlale <br /> Requester's Name (please print) Agency Contact <br /> �Name (please print) <br /> GI,�-b G (e..n 11 i,✓ So ,1 e 12.T 11�iopl_� /YCTifi(17 .�/O <br /> Address Address <br /> ro(cam,.. « 9.-63o <br /> City, State, and Zip <br /> //Code City, State, and Zip Code <br /> Signature: G Q /� Sict ature: <br /> Title: 6e a l o_�,r{ Title: <br /> Telephone: ( q 1 ) 9ks" -2e y9 X- 13 Telephone: <br /> FAX: ( 916 ) j?9S-- la r13 FAX: (ro9) <br /> Date: L/� A 3 Date: �/Q�//3 <br /> E-mail: S14.velc. P5w(.l* @ E-mail: <br /> �i��� - 1g May 2011 <br /> wcr_request_envcleanup_20110518.doc -q'✓_ <br />