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%.Nor Now <br /> STATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR.Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NORTH CENTRAL REGION SOUTH CENTRAL REGION SOUTHERN REGION <br /> 2440 Main Street 3500 industrial Blvd. 3374 E. Shields Ave Ste A7 770 Fairmont Avenue <br /> Red Bluff,CA 96080 West Sacramento, CA 95691 Fresno,CA 93726 Glendale, CA 91203 <br /> (530)529-7300 (916)376-9612 (559)230-3304 (818)500-1645 ext.233 <br /> (530)529-7322(Fax) (916)376-9676(Fax) (559)230-3301 (Fax) (818)543-4604(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 unauthorized 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(Water Code Section 13752). <br /> Requests must be made on the form below, signed and submitted to the appropriate DWR District Office. Please <br /> provide the township, range, and section of the property where the study is to be conducted. Attach a map or a <br /> sketch with a north arrow, and provide as much identifying information requested below as possibfe;-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 /> Project Name:Sarale Farms County. San Joaquin <br /> Street Address 16500 Clifton Court Road Ciy Stockton <br /> Clifton Court Forebay Quadrangle <br /> Township, Range, and Section. T1S, R4E, Section 11 Radius:2, 000 square feet <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Advanced GeoEnvironmental Inc_ San Joaquin County EHD <br /> Requester's Company Regulatory AgenFy Name <br /> lmlro'as- <br /> Daniel Villanueva Vick McCartney <br /> Requester's Name(please print) Agency Contact Name (please print) <br /> 837 Shaw Road 600 East Main Street <br /> Address Address <br /> Stockton Californiar 952 .5 Stockton, California, 95202 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Si nature: Signature: do <br /> Title: Staff Geologist Title: Senior RENS <br /> Telephone: (209 467-1006 Telephone: 209 468-9852 <br /> FAX: ( 209 ) 467-1118 FAX: 209 46¢'�-3433 vn 10•2s-It <br /> Date: 10/25/2031 Date: 0 Cho_ e 2-T 01 <br /> E-mail: dvillanueva@advgeoen-v.com E-mail: vm cartney@sj cehd.com <br /> U- S-11 <br /> wer_request_enveieanup_20110518.doc 18 May 2011 <br />