Laserfiche WebLink
Apr. 30. 2007 4: 15PM ATC GROUP SERVICES INC. No, 0390 P. 2 <br /> A op • <br /> STATE OF CALIFORNIA THE RESOURr eroury ARNOLD SCHWAR2ENEGGER.Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento. CA 95816 Red Bluff, CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (918)227-7632 (530)529-7300 (559)230-3300 (818)500-1645 ext.233 <br /> (916)227-7600(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 jWater 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 /> ProlectName: FOIrMQY `(YNY' PYOZrV County:Swa Tom".m <br /> Street Address: 1510 j?74 aoy ey,ml i0ad City: C-Mlik0Y1 <br /> Township Range and Section: IVIG -26 Radius: 1 Mt Q. <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> AfC A%OcWes �YNC . Sok rJOa1LAI&nOV- <br /> Requesters Company Regulatory Agency Name <br /> A nhy Wmy i I 902( I)VA,YAnJ <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Ill? Wle PAim AVe . Smite 201 (,OD . (BAIN ST <br /> Address Address <br /> waem I Col 115SS1 5 -roC'%fh �,� tis ZoL <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: Lc� %4__1 Signature: L� )�" <br /> Title: Sta�E OIQO�OQiSfi Title: ,sPnArof (;ZEl-K <br /> Telephone: (201) S10� ' '22-21 Telephone: (Zc( ) g6(R-03 3 <br /> FAX: (2.0,11) SI.q ' 22 2 5 FAX: (?0? ) L{ <br /> Date: f �J� ' u� Date: <br /> E-mail:WYMY.y19 Nyyllli)htC0M6C1GtM L" E-mail: j�Uwojoj(a) d .!40 <br /> oa e,.ai onna <br /> u,n•r..,uH nn•minnnun 7M&AA OQ.inn <br />