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STATE OF CALIFORNIA - THE RESOURCES AGENCY ARNOLD SCHWARZEN EGGER 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) 500,1646 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 of conducting the environmental cleanup study. <br /> Proe County: <br /> n op �l n <br /> Street Address: 2\ o �, Cov .&fij Glvb City: Toto; Iz- on <br /> -t-1 Ar RG£ <br /> Township Range, and Section: Radius: til , ) Q5 _ <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> ScL.l 30C�cLvxn Cor 't <br /> (L.CIAD � toy; ronMe•n"t<k \ 1-{y all neXAmr.rf- <br /> Requester's Company Regulatory Agency Name <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> � SO vl4� n 'Drve. � i) D �a1•`r Mo-2n Sdh^Ze_A- <br /> -- — Address reSS <br /> F .A c o. r C'_4 15 3 (0 SAoct t-a, ) ICA 1? 5 0 2 <br /> City, State, and Zip Code City, State, a ip Code <br /> Signature: ( 2 ! Signature: <br /> Title: Cr "I 511± Title: �+ L / <br /> Teleptrone: (ejI (, ) i k5 - ? 7 + . r4_ Tele hone: 967 <br /> FAX: (el t )SS - 2 r 3 FAX: / /��— <br /> Date: ( - (o - 1 (7 Date: 6 /(e <br /> E-mail: Zptr_ /A'L4vv rlc. E! sjr elnelCoen <br /> wer equestenveleanup_20090928.doe SJ `6a C - 2�8Septe <br /> mber <br /> 2009 A / l — <br />