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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 /> 3500 Industrial Blvd. 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> West Sacramento,CA 95691 Red Bluff,CA 96060 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)376.9612 (530)529.7300 (559)230-3300 (616)500-1645 ext.233 <br /> (916)376-9676(Fax) - (530)529.7322(Fax) (559)230-3301(Fax) (610)5434604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT—AGENCY STUDY <br /> (Government Agencies and their Authorized Agents) <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 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: D cT�—riXP4 �[/Llti�(1 �-- County: SdhT 7ti <br /> r <br /> Street-Address: City:,I-rgGy andLot&pp <br /> Township Range and Section:,3ee "f4sl Radius: <br /> (Include entire study area and a map that shows the area of interest.) WV605S>°5 <br /> Authorized Agent Company Name Government Agency Name <br /> I 1020 Sum Or <br /> Address Address <br /> wokVda,� , rA l 0- <br /> City, State, and Zip Code City, State, and Zip Code 14 <br /> 01L E? WkW2 ( IPG <br /> Authorized Agent Name (please print) Agency Contact Name (please print) <br /> Signature: Si nature: Jn( p� nt V <br /> Title: Title: MGN e1' <br /> Telephone: ( ) Telephone: (q I(:�7) <br /> FAX: ( ) FAX: ( r) q <br /> Date: Date: l–e 6�4a✓y 10, <br /> -E-mail: <br /> 0rE-mail: E-mail: t Y)I�WV}e� @W�Iu b�� �GfS• G ,a�V <br /> J <br /> war request_agencystudy_20090107.doc g 7 January 2009 <br /> - hv[qu <br />