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STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,Governor <br /> DEPARTMENT OF WATER RESOURCES �T <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3500 Industrial Blvd. 2440 Main Street 3374 E. Shields Ave Ste A7 770 Fairmont Avenue <br /> West Sacramento, CA 95691 Red Bluff,CA 96080 Fresno, CA 93726 Glendale,CA 91203 <br /> (916)376-9612 (530)529-7300 (559)230-3300 (818)500-1645 ext,233 <br /> (916)376-9676(Fax) (530)529-7322(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: Pacific Mini Mart/Pacific car wash County: San Joaquin <br /> Street Address: 4511 Pacific Avenue City: Stockton <br /> Township, Range, and Section: Radius: 2,5110 feet <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Advanced GeoEnvironmental Inc. San Joaquin County Environmental Health DPT <br /> Requester's Company Regulatory Agency Name <br /> William Little <br /> Requester's Name (please print) Agency Obntact Name (please print) <br /> 837 Shaw Road 601D East Main Street <br /> Address Address <br /> Stockton, CA , 95215 Stockton, CA 95202 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: Signature:`64c � <br /> Title: Geologist Title: �ra�f 0.r-. C_por cl cyta tII r <br /> Telephone: 209 467-1006 Telephone: ( 209 ) 468-3420 - <br /> FAX: ( 209 } 467-1118 FAX: 209 ) 1464-0138 <br /> Date: 03 April 2009 Date: `41310 <br /> E-mail: Ilittle@advgeoenv.com E-mail: K% IL, <br /> r; 0 D s� c- C,611-\ <br /> wcr_request_envcleanup_20090107.doc 7 January 2009 <br />