Laserfiche WebLink
i <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 95816 Red Bluff, CA 96480 Fresno, CA 93726 Glendale, CA 91203 <br /> (916)227-7532 (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 /> I 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 /> i <br /> i <br /> Project Name: Updated Sensitive Receptor Study County: San Joaquin <br /> Street Address: 2375 North Tracy Blvd., Tracy, CA City: Stockton <br /> I <br /> Township, Range, and Section: T2S R5E Secs 16, 17, 20, and 21 _ Radius: 2,000 feet <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> I <br /> SECOR International San Joaquin County Environmental Health Department <br /> Requester's Company Regulatory Agency Name <br /> Kimber Collins Mr. Harlin Knoll <br /> Requester's Name (please print) Agency Contact Name (please printf <br /> 3017 Kilgo re Rd. Suite 100 600 East Main Street <br /> Address t Address <br /> Rancho Cordova, CA 95670 Stockton, CA 95202 <br /> City, State, and Zip Code City, State, and Zip Code - <br /> 1 <br /> Signature: i r Signature: <br /> " kll�e <br /> Title: Project Scientist Title: Wif <br /> Telephone] (916) 384-0733 Telephone_ : (20.9) 468-3442 <br /> FAX: ( 9 16 861-0430 FAX: (209) 4F38 <br /> i <br /> Date: Sy�j r - Date: s— 17 0'1 <br /> r 7— <br /> E-mail: keolfins@secor.com E-mail: hknoll@sjcehd.com <br /> wcr request-envcleanup_20060426.doc 26 April 2006 <br />