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STATE Q T 1T OF WATER REbURCE ENCY - ARHOLD SCNWARZEN-000.ER:r�*.a,=�: <br /> TATE C <br /> RESOURCES <br /> NORTHERN REGION NORTH-CENTRAL REGION SDUTH-CENTRAL REGION SOUTHERN REGION <br /> 2440 Main Street 3500 Industrial Blvd, 3374 E.Shields Ave Ste A7 776 Fairmont Avenue <br /> Red Bluff,CA 96080 West Sacramento,CA 95691 Fresno,CA 93728 Glendale;CA"91203 <br /> (530)529-7300 (916)376-9612 (559)230=3300 <br /> (818) 6kli 233 <br /> (530)529-7322(Fax) (918)376-9676(Fax) (559)23G-3301(Fax) (81 B)5131.4604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT AGENCY STUDY <br /> (Government Agencies and their Au'thorize&Agents) <br /> Under California Water Code Section 1:3752,the agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for-.bur authorized agent named below to i <br /> inspect or copy, Well Completion Reports filed pursuant tSection 13751 to make a study. <br /> In accordance with Section 13752, information obtained from these reports shall be kept <br /> confidential and shall not be disseminated,published; or made available for inspection by the <br /> public, The information shall be used only for the purpose of conducting the study. Copies <br /> obtained shall be stamped CONFIDENTIAL and shall be kept in a restricted file accessible only to <br /> agency'staff or the authorized agent for this study. <br /> Project Name:. APO .r-�'T�(� � A)b County; JWn Jad�u trt <br /> Street Address: w ILSb Jl�:_wA City: - S'fOtle.CD� <br /> Township, Range, and Section: - S, Z Radius: .. 2,;(,5D 'm TT <br /> (Include entire study area and a map that shows the area of interest) ' <br /> Authorized Agent Company Name Government Agency Name <br /> - &S4 AL wt SR <br /> Address Address n 4 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Authorized Agent Name(please print) Agency Contact Name.(please print). <br /> i F <br /> Signature: R S' nature: <br /> Tide: Title: c <br /> QGki4 ' <br /> e Q ' - <br /> Telephone: <br /> ( qi'(�), `f$S• .20 °1 Telephone: (Z ) B j(p, <br /> Te — - <br /> FAX: <br /> � ,: e. FAX..( 209 <br /> Date: . q_7. - Date: 24// <br /> E-mail' 1u1�t. Pu�s�'� OU"CA+�.�S�LK; 'E-mail: 171 t 10'elx w P5' ,,e V.COM- <br /> GeV" <br /> 5 <br /> wcr request agencystudy_20090928.doc 28 SWensber20M <br /> i <br />