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l <br /> i <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) 230-3300 (818) 500-1645 ext. 233 <br /> (530) 529-7322 (Fax) (916) 376-9676 (Fax) (559) 230-3301 (Fax) (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 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 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 ofr conducting the environmental cleanup study. �7 T /J <br /> Project Name: �,NL'�VrVP1 6 ryfr e 'ga t�. 9y05�1 _ County: bN( //1uoyitir\ <br /> Street Address: { tevoi City: 54CKlon <br /> Township Range and Section: do 123 090 21 Radius: 0> 5 /vli <br /> (Include entire study area and a map that shows the area of interest.) — (maximum 2 miles) <br /> lt , top <br /> RequestteCs Company Regulatory Agency Name <br /> �Jre� KYc � 6ie � Li5a 1r(e ly <br />',III Requester's Name (please print) Agency Contact Name (please print)����� <br /> / Sur7C 25 <br /> 95d 'C/Ih r�i iVP ! ✓1 1w <br /> Address Address <br /> IO�Sow1 , ( ytl!'tOrnr"a r g5G 30 S a�h , l' (firn� 4=g9s�Os <br /> City, State, and Zip Code City, State, a Zip Code <br /> Signature: Si natur <br /> q � e <br /> Title: T kRAt4alf r Title: <br /> Telephone: ( 1116 ) . ��� 2079 x Telephone: <br /> FAX: ( qIG ) , 85 . 2D 3 FAX: <br /> Date: 2012 Date: 9/o?Q/o? <br /> E-mail : E-mail : / e ,, M -f t' Plari0eoaf2) <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br /> i� <br />