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Mar-10-03 03:44pm From-5ROM Ali;71 216 835 <br /> VT-T14 P.002/002 F-738 <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES GRI►Y DAMS GOvarROf <br /> CENTRAL DISTRICT NORTHERN DISTRICT <br /> 3251 5 Street SAN JOAQUIN p1STRICT SOUTHERN DISTRICT <br /> 3251 5 Street <br /> CA 958f6 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento, <br /> ac meat , Red Bluff, CA 960$0 Fresno, CA 93723 <br /> (530)529.7300 (559}230-3300 Glendale CA gg2p3 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fez) (8?8)543-4600 <br /> (818)543-4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract No. T 5 l` � <br /> County � <br /> Township, Range, and Section i 3iJ 26E. s 3f-j i?7E TO 3 } Radius <br /> (Must include entire study area and a map that shows the area of interestjd f <br /> !Under Califomia Water Code Section 137;52, the agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for our authorized agent named below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to (check one): <br /> ❑ Make a study, or, <br /> Perform an environmental cleanup study associated with an unauthorized release of a <br /> contaminant within a distance of 2 miles. <br /> In accordance with Section 13752, information obtained from these reports shall be kept confidential <br /> and shall not be disseminated, published, or made available for inspection by the public without <br /> written authorization from the owner(s) of the well(s). The information shall be used only for the <br /> purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall be <br /> kept in a restricted file accessible only to agency staff or the authorized agent. <br /> �3R OL.v <br /> Authorized Agent �• <br /> Governmen or Regulatory Agency <br /> Address Address <br /> City, State, and Zip Code City, State, and Zip Code <br /> Si nature Si nature <br /> Title �a c� �CI 77S Title �heer�h lam( <br /> Telephone (�rlc, ) S"3 c 7 Tele hone D,9 <br /> Fax I(G) 6 $� $�}Sr' Fax X09 fo 0 <br /> Date a Date �� cxa 3 <br /> E-mail �!?dGl ? <br /> -- ._�'�t� E-mail S'Ce (f <br /> 6 June 2001 <br />