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CENTRAL DISTRICT <br />NORTHERN DISTRICT <br />901 P Street I! <br />2440 Main Street <br />Sacramento, CA 95814 <br />Red Bluff, CA 96080 <br />(916) 651-075311 <br />(530) 529-7300 <br />(916) 6510726 (Fax) <br />(530) 529-7322 (Fax) <br />SAN JOAQUIN DISTRICT <br />3374 E Shields Ave Ste A7 <br />Fresno, CA 93726 <br />(559) 230-3300 <br />(559) 230-3301 (Fax) <br />SOUTHERN DISTRICT <br />770 Fairmont Avenue <br />Glendale, CA 91203 <br />(BIB) 500-1545 ext. 233 <br />(818) 5434604 (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 uhauthorized 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 f Water Code Section 13752). <br />Requests must be made on the fnrm below, signed and submitted to the appropriate DWR District Office. Please <br />provide the to range, and section of the property where the study is to be conducted. Attach a map or a <br />sketch with ainorth 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 />ProiectName: F-Ai:TAGP_ 10S p,IKANGCOARM (NC. County:SA)i u1N <br />Street Address Zi5i Seii� AiyR pom � OiN� City: STOG4i'YDN <br />1 <br />Township Range and Section: 01 N WE SQcTtpNS22�`23 Radius: 7_000 <br />(Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br />Ell c <br />Requester's Company <br />f)mlt Nl ) <br />Requester's"Name (please print) <br />ZR� IMoRFAiz NivNLtE <br />Address <br />FAX: (I z5) &62-47 W <br />Date_�/I ZiTa{O <br /><••t3oAQUW CAucaTY F�tVtP1MeNIAi, }{F1alX4ic <br />Regulatory Agency Name <br />V1GTbW/k I�A�ef <br />Agency Contact Name (please print) <br />3o`f E USER Auous, 31° F"oR <br />Address <br />STOCIC#00 CA 952.02— <br />City, State, and Zip Code <br />Signature: <br />Title: ssEh i Or- 'R <br />Telephone: (20 1) 460$ -345(v <br />FAX•(20q) 4G$-3433 <br />Date: 8 $ l 0G <br />E-mail: E-mail: V mecair+11f��d <br />wcr request-envcleanup 20060706 doc 07 July 2005 <br />