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Aug. 1. 2006 10: 32AM Ady.anced GeoEnvironmental No. 5656 P, 2/3 ` %MW %.rh STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,Governor DEPARTMENT OF WATER RESOURCES CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT 3251 S Street 2440 Main Street 3374 E. Shields Ave Ste A7 770 Fairmont Avenue Sacramento,CA 95816 Red Bluff, CA 96080 Fresno,CA 93726 Glendale,CA 91203 (91e)227-7632 (530)529-7300 (559)230-3300 (818)500-1843 ext,233 (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)543-4604(Fax) WELL COMPLETION REPORT RELEASE REQUEST AND CONFIDENTIALITY AGREEMENT REGULATORY-RELATED ENVIRONMENTAL. CLEANUP STUDY Well Completion Reports associated with wells located within two miles of an area affected or potentially affected by a known unauthorized release of a contaminant will be made available upon request to any person performing an environmental cleanup study associated with the unauthorized release, if the study is conducted pursuant to a regulatory agency order(Water Code Section 13752). Requests must be made on the form below, signed and submitted to the appropriate DWR District Office. Please provide the township, range, and section of the property where the study is to be conducted. Attach a map or a sketch with a north arrow, and provide as much identifying information requested below as possible;-additional paper may be attached if necessary. By signing below, the requester acknowledges and agrees that, in compliance with Section 13752, the information obtained from these reports will be kept confidential and will not be disseminated, published, or made available for inspection by the public. Copies obtained must be stamped CONFIDENTIAL and kept in a restricted file accessible only to authorized personnel. These reports must not be used for any purpose other than for the purpose of conducting the environmental cleanup study. r Project Name: Low P'n u, ATUL- [mass MY TtAC0 County: S(Atn 30HWO O Street Address: D O �0 ) N "I RoOt City: c} h "r ' Township, Range, and Section: I � �' Radius: (Incl ude entire study area that and a map th ltt sllhows the area of interest,) (maximum 2 miles) (feo& (oy,� V(J�1 `-' �� n) JCt/�(3ll Im C C')'1A):S.'�j Requester's Company Regulatory Agency Name 6�,jJ 1R_v(V M;WtAL HeAI,-; -) ` Requester's Name (please print) Agency Contact Name (please print) P1 Shayj ROLL& 30Y E - WLtt�Ll2 ACd�dr_es(s�(_,, /� n 1 Address J +V Ct�� UA I (x " 5� 5 STc,r fe—TyC',4 City, State, an ip Code City, State, and Zip Code Signature: r Signature: (Cnd CA oy� Titter( AV �C 1 ,'l t/tT?5� Title: o,tfo I o 2 Telephone: ( Dvu ) 1 t 4'q00 Telephone: !>I FAX: ( ) �(.y1� l FAX: { 2-09 3 y`(O Date: 0g"0 UDS Date: S I 1 1 O E-mail: aae t cke a l'ot KC00/11 E-mail: wcr request-envcisanup_20060426.dx 26 April 2006