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08/18/2006 16:43 19256024'20 ETIC ENGINEERINY PAGE 02 <br /> STATE CF CALfFOR 1�IA�TNE RESOURCES AGeNCY AkNOLD SCHWAREEWFJ'GER�Go+n�r Lot <br /> DEPARTMENT OF WATER. RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 901 P Stmet 2440 Main Stmet 3374 E.Shields Ave Ste A7 770 Fairmont Avenus <br /> Sacamrrito, CA. 95814 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)6510753 (530)529-7300 (559)230-3300 (il 500-1645 ext.233 <br /> (9161651 0726(Fax) (530)523.7322(Pax) (559)230-3301 fW, (V$)W-4604(Fm) <br /> WILL COMPLETION REPORT RELEASE REQUEST AND CONFIDENTIALITY AGREEMENT <br /> RE[9UL ,TORY-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 knavn unauthorized release of a contaminant will be made available upor request to any parson pefoming <br /> an environmental cleanup study associated with the unauthorized release if the study is conducted pursuant to a <br /> regulatory agency order AVater Code Seo:ion 13752). <br /> Requests must Im made on the form below,signed and submitted to the appropriate]WR District Office. Please <br /> provide the township, range, and section of the property where the study i3 to be conduced. Attach a Map cr a <br /> sketch with a north arrow,and provide as much identifying information reques`ed below as possible:-additional <br /> paper:T12y be athiuhed if necessary. <br /> By signing below,the requester acknowleeges and agrees that, in compliance with Section 137E2,the <br /> information obtained from these reports will be kept confidential and will not be disseminated, published,or <br /> mace ar ffailable for inspection by the public. Copies obtained must be starlped CONFIDENTIAL and kept in a <br /> restricted file aocossible only to authorized personnel. These reports mus:not be used for any purpose othe- <br /> than for the purpose of conducl:ing the environmental cleanup,tu dy. <br /> Project Name: Fortner Exxon RAS 147.3942 T _ Coun : San Joaquin _ <br /> Street Address: 4444 North Pershinc)Avenue City: Stockton <br /> Towrtsh c, Range and Section: M 021'4 06E 28 Radius: 1 mile <br /> (Include entire study area and a map that shows the ares of Interest.) (maximum 2 miles) <br /> San Joaquin County Public Health Services <br /> ETIC EngineeringEnvironmental Health Division <br /> Requester's Company Regulatory Agency Name <br /> Yuko Itilamiya� Harlin Knoll — <br /> Requesters Name (please print) Agency Contat Name(please print) <br /> 2285 Morello.Avenue 304 E. Weber Avenue, Third Floor <br /> Address Address <br /> PieaFant Hill, CA. 44523 Stockton, California 86202 <br /> City, State, and Zip Code City„State, and Zip Code <br /> S {K-ignatu�r <br /> Title: Staff Geoll�gist Title: 64j <br /> Telephone: (925) 6024710 Telephone: (209) 468.3442 <br /> FAX: (925) 502-4720 FAX: (209/) 46"1 8 <br /> Date: irate: <br /> E-mail: ymamiya_ta"leticeqacom E-mail: _SSGEH Cd/✓t <br /> wcr request-envcleanuu 20060706.dco 07 My 2006 <br />