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i <br /> l� <br /> si STATE OFGALIFORNIA-1fit NATURAL RESOURGrzS'AGENCil EC3NtliNB,Q..'BROINN 3Ct•Goverr►or <br /> DEPARTMENT OF WATER RESOURCES <br /> NGRTHMREGION, NORTH GFP rRALRE.GION '50UM dENTRIIL RLGI[}N SOUTHERN REGION, <br /> '2440 M;l jn Street 35001nddw Bial f314 3374 E:.Shields Ave Ste A7 770 F-*moot Avenue <br /> Red,1310,CA 95080 Wl mt Sacramento,-CA 9.5691 Fresno,CA 93728 Glendale,CA 91203 <br /> y <br /> {530)529-7300 {9iii}37&9512 .(559)230-3300 ($!8)r,004645,:ex.233 <br /> r {530)'529-7322(Fa)) ,(916)376-9676.(Fax) (553}230-3301_(fax} .(818)`.'')43-4W4.(F") <br /> r <br /> R WP_LL COMPLETION1 REPORT RELEASE REQUEST A N.b CONFIDENTIALITY AGRGEI1 ENT <br /> REGULATORY-RELATED ENVIRONMENT.AL CLEANUP ST.UDY <br /> 3 Well Completion.Reports associated with wells located within two)riles of ari area affected or potenfially affected <br /> E by a known unatifliorizec]release of a contarrlir�ant.will be made available upon request to any.person performing <br /> an environmental cleanup study associated with.the.unauthorized release, if the studyas conducted'pursuant to a <br /> regulatory agency order)Water Cade Section 13752).. <br /> 3 Requests must be made-on the fo"below; sighed andsdbmiited.iia-the appropriate Dully DiWiet Office R16ase <br /> provide the township,'range.,and section,of:the property wJ'ere.-the study is to be conducted. Attach,a map or a <br /> sketch'With.a north arrow;.and provide as much identifying Ofo matjoh requested:below as posssible;;additional <br /> paper may be-attached if necessary. <br /> B,y:sign'ing,betow,the requester ackhowwledges andazdrees that;in compliance with)Section 13752 11J6 <br /> ;information obtained from these-reports will be kepi co..hfideritial'and tvill not be disseminated,ppblished,or <br /> made:available for inspection by the-puhlic. Copies obtained must-be stamped CONFIDE TIAL and kept in a <br /> restricted fiJb accessible only to authorized personnel. `these reports-must not be used for any purpose other <br /> than for the purpose-of conducting.ttle environmental cleanup study: <br /> Projedt Name:.Sar l¢ Farms County: Sari �7oa 'u <br /> Clifton Court. Road, x- St ocktctrx <br /> Street Address: . City; <br /> Clifton- -Court Fdrebay Quadrangle <br /> Township,-Range, and Section 'T'lS: RdE, -Section 11 'Radius:-21'00D sguard feel~ <br /> (Iridtide entire-study area arid:al marl-that shouws the aiea of interest.) (riiaziitiusn.2iniiesj' <br /> .Advanced GeoRnvironmental-_Ind-, :Barr �3oaqu�'xi County 814f), <br /> Requester's Company .Regtilatory Agency:Name <br /> � ;hllttn•zs- <br /> _ F5ani-el Villanueva. . V I;d kk 1+MCCartz>ey <br /> { Requester's.Name(please print) Agency Contact Name(please;pr.int) <br /> j 837 8haw Road 6.00 "trait MAin ;8t reet <br /> Address Address <br /> Stockton Califoknia 9.5225 Stockton, California., 95202 <br /> City;State, and.Zip Code City, state, and.Zip Code <br /> Signature, <br /> Si nakfre: ' ' <br /> Staff <br /> Title:-Staff <br /> Ceolo gist� 't'''itle: Senior �REtis <br /> ' - <br /> Telephone: (209 ) 467,-'1006 Telephone:,(2 0'�.. b2 <br /> .8' 3.43: >rrn .o-zs--» <br /> FAX:{.209 467-1118 FAX: (.2!99. 460�"e3-3t <br /> 1 - <br /> ©ate: .10/25/2011 Date: <br /> E-mail dvillanueva0advgeoenv.00m E-mail: v-m cc,artne"sjcehd-com <br /> 1 <br /> v:cr_rcgtfest eavclearnep__2011o51tf:dac 18 May 2011 <br /> i <br /> 1 <br /> i <br />