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E00-a 7uicy�� <br /> %woe <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY GRAY DAVIa rovemor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento, CA 95816 Red Bluff,CA 96080 Fresno, CA 93726 Glendale, CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230-3300 (818)543-4600 <br /> (916)227-7600(Fax) (530)529.7322(Fax) (559)230-3301 (Fax) (818)543-4804(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized <br /> Agents) <br /> Project/Contract No, I I(4 0 t) Se'm(k Ma«4eCd. County c�Yl fou A�i,t i Y) <br /> Township, Range, and Section Radius_r/2 M i Imo. <br /> (Must include entire study area and a map that shows the area of interest.) <br /> Under California Water Code Section 13752, the agency named below requests permission from <br /> Department of Water Resources to inspect or copy, or for our authorized agent named below to <br /> inspect or copy, Well Completion Reports filed 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 stamped CONFIDENTIAL and shall be <br /> kept in a restricted file accessible only to agency staff or the authorized agent. <br /> San boa Vi'm eovnfy <br /> 02 1° Eny; ronmenfa1 ) ea14b 'Defor+rnerL, <br /> Authorized Agent Government or Regulatory Agency <br /> V,2 Per iC;k 5 Str-ee.- 304 E . Weber Averwe <br /> Address p Address <br /> c�om0`Yhof CA 254-1(e S+0ck*0-A ) CA 95202 -2?08 <br /> City, State, an Zip Code City, State, and Zip Code <br /> Signat <br /> u <br /> re Si nature i C <br /> Title ) 1DX i fD1�� VCC�Id tS� Title Se»t'r,r -R. L. H . S. <br /> Telephone ( 700 Telephone (20q) :14, a - 3451 <br /> Fax (7071 {35- 10&+9 Fax ( 2 o 9) 4/e S - 3433 <br /> Date arGk 2A Z.60 Date MAYA 24) .2005- <br /> 1 f <br /> E-mail lVlt QCAmiprrlq+' eAy. E-mail v mccar-1-n e SS 1' a6d.cpm <br /> 6 June 2001 <br /> ZOIEO"d 6b99 S£6 LOLT HINSWU9 9T:£T SOOZ—VE—aUW <br />