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09017/2008 13:47 925371591.5 GEOCON - EAST SAy <br /> • PAGE 02102 <br /> STATE OF CALIFORNIA,THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,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 95818 Red Bluff, CA 96080 Fresno, CA 93726 Glendale, CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230.3300 (818)500-1645 ext.233 <br /> (916)227.7600(F®x) (530)529.7322(Fax) (559)2303301 (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 maybe 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 /> Prosect Name: County: <br /> Street Address: �3� .19 5, 5if F 2oa / City: TlY� AYii�ncY.�ditxr <br /> Township, Ranger and Section: T2. S Radius: <br /> (Include entire study area and a map//that shows the area of interest.) (maximum 2 miles) ,/ <br /> Requester's Company Regulatory ency Name <br /> R—Ick U rce SSc K. is s��4E� �/• �N1i;W,4 <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> T/ Sr`��f l DO ze- 7�faL.. moi! <br /> Address Add <br /> tl� ore <br /> Z�a�+ <br /> . Gt4 9Y�3a�.ZJaS (W �Szorl <br /> City, State, ahlid Zip Code City, State, and Zip e <br /> SigneSignature <br /> Title: Title: `� <br /> Telephone: � S �— �j Q� Telephone: (�[�9 )rTIOJ� 3TS <br /> FAX; / rj) 3 71— 5-21E: FAX: <br /> Date ZZ/41Q Date: —d O <br /> E-mail: �/L°G F�EOr7/06 .L4,uc E-mail: �hGric�uv�vL S)C641A ��"` <br /> wcr requeebenvdeanup_20060426.doc 25 April 2D08 <br />