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TATE OFCALIFORNIA C Y DAVIS Govern r <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 SSM-taut 2440 U61a 5treat 3374 Easi 6hiwids Avenin 'i'7 U i=aifmont Avenue <br /> Sacramento,CA 95816 Red Bluff,CA 96080 Fresno,CA 93728 Oendale,CA 91203 <br /> (016)227 7632 (530)528-7300 (559)2303300 (810)543-4640 <br /> � 1 l 227•'C??(F� (53J)52C 7322,irag1 X.,0� <br /> �......., , } do i of:,ry3-•:n+w��a�) <br /> WELL COMPLETION REPORT RELEASE AGREEMEN i AGENCY <br /> %Gcreinnient area Requ;ctivi r Aviluitub wW their Authorized agents) <br /> Project/Contract No. II MI: �; AA�i 13"&j&eii CA County Ga -jA(ZU6r3 <br /> 'i ownsnip, range, and Section I 1-+;j R, , gc.r- 1.4 1 _Radius %% 00b <br /> (Must include entire study area and a map that shoves the area of interest) <br /> Under California Water Code Section 13752,tyle agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for our authorized agent named below to <br /> i�Is-;ed or cup f,Well Completion Reports fled 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 stomped CONFIDENTIAL and shall be <br /> kept in a restricted file accessible only to agency staff nr the authorized agent. <br /> 0 -4IZw r- N �L~ <br /> LIA-� SA-,+ oaQueiJ . <br /> Authorized Agent Government or Regulatory A ency <br /> GACRP,r�-f O, C a 1�7 16S fSi c�C IL o r`1 (fA a 2c,,r2— <br /> City, State, and Zip Code City, State, a Zip Code <br /> Signature -81cinature <br /> Tit Lo Gr-r S i ale (Z E • (41 S <br /> Telephone f 4!4)-6 aO± Teleptignest), <br /> Fax t b 6 7 .- 263 O CD Fax '-f C7! 3Y 33 <br /> f <br /> Date 7 2$ OS- Date Q <br /> F 1 <br /> E-mail '^T+-Vaul, j E�m it S '�-�kA, C cid <br /> 6 J(rne 2001 <br /> 600/x0018 00-01N3wvHaas-sun aoszsz99I.s XuH E0'91 90031901LO <br />