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SITE INFORMATION AND CORRESPONDENCE
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EHD Program Facility Records by Street Name
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3500 - Local Oversight Program
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PR0545872
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SITE INFORMATION AND CORRESPONDENCE
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Last modified
7/21/2020 3:41:07 PM
Creation date
7/21/2020 3:26:22 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0545872
PE
3528
FACILITY_ID
FA0025947
FACILITY_NAME
JAYS MINI MART
STREET_NUMBER
3302
Direction
N
STREET_NAME
WEST
STREET_TYPE
LN
City
STOCKTON
Zip
95204
APN
11705037
CURRENT_STATUS
02
SITE_LOCATION
3302 N WEST LN
P_LOCATION
99
P_DISTRICT
002
QC Status
Approved
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EHD - Public
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STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER Govemor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 901 P Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95814 Red Bluff,CA 96080 Fresno, CA 93728 Glendale, CA 91203 <br /> (916)651-0753 (530)529-7300 (559)230-3300 (818)500-1645 ext.233 <br /> (916)651-0726(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 i <br /> regulatory agency order jWater Code Section 13752). j <br /> Requests must be made on the form below,signed and submitted to the appropriate DWR District Office_Please I <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 i <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 /> 1 <br /> Project Name: �r^y' S 4O yr-V+ County: S", <br /> 1 <br /> Street Address: We s& city: Sf <br /> ck� <br /> Township, Range, and Section: 72, N 91- Sse+ 15 26.35 34 Radius: V 14-71 le <br /> (include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> 4 <br /> t <br /> ATC, A-55 j +�e S Env ' menf-a r i <br /> Requester's Company Regulatory A ncy Name jj ea+h Depay- wLefj+ [ <br /> Requester's Name (please print) Agency Contact Name (please print) / € <br /> � i <br /> (� T t o" p- ,r n Ave,>ySut4c 2c:7 ►VL <br /> i — 6 0 0 � I n <br /> Address Address <br /> �A 5 i S+ t,-,k+o eA gS202 <br /> City, State,and Zip Code City, State, and Zip Code <br /> . i <br /> i <br /> Signature: Signature: } <br /> Title: , 7✓ Title: Se n i O Y-Re q;5+?_rJ � '� i <br /> � 1 n�a� <br /> i <br /> sf <br /> Telephone_ �7 ) � Telephone: (;.4q) 4�, 8 -98 S2 <br /> FAX: q ) 542-2227 FAX: ( 20 q) 4 C — 3-43 3 <br /> Date: -- Erl !sI /Z� Date: Apr ,1 22,1 _2 O 0 a j <br /> E-mail: Kvu�¢yfh4 �+ GAfSyL1_ f. 6"E► E-mail: V Me_CQlr+" geyrd S1ce6j .C4m <br /> I <br /> I <br /> { <br /> wcr request-enveleanup__20080706.doc 07 July 2006 I <br /> i <br />
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