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i <br /> I <br /> STATE OF CALIFORNIA - THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT i <br /> 901 P Street 2440 Main Street 3374 E. Shields Ave Ste A7 770 Fairmont Avenue I <br /> Sacramento, CA 95814 Red Bluff, CA 96080 Fresno, CA 93726 Glendale, CA 91203 I. <br /> (916) 651-0753 (530) 529-7300 (559) 230-3300 (818) 500-1645 ext. 233 <br /> (916) 651-0726 (Fax) (530) 529-7322 (Fax) (559) 230-3301 (Fax) (816) 543-4604 (Fax) <br /> WELL COMPLETION REPORT RELEASE REQUEST AND CONFIDENTIALITY AGREEMENT i <br /> REGULATORY-RELATED ENVIRONMENTAL CLEANUP STUDY <br /> Well Completion Reports associated with wells located within two mites 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 jWater Code Section 13752). <br /> 1 <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 I <br /> paper may be attached if necessary. <br /> By signing below, the requester acknowledges and agrees that, in compliance with Section 13752, the 3 <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 4 <br /> than for the purpose of conducting the environmental cleanup study. <br /> tt a <br /> Project Name: �)nq T's�t Re5ol: County: $ah )Jo� ou;a <br /> Street Address: 11530 Wayj�jj L- Mile koj City: VbrLZ7ot-+ <br /> / 1 <br /> Township Range and Section: T9 N RE C )ui 5 6 Radius: I L. ; IC <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> � A <br /> H� SSoc�� leY I <br /> PC, J ESD <br /> Requester's Company Regulatory AgOncy Name <br /> jr Lle <br /> INofilleArA <br /> Requester's Name (please print) Agency Contact Name (please print) j <br /> I11 LaLre Pn 1" Ave, , Soar Zvi 60a is 904 <br /> Address Address j <br /> C4 g+535' 1 <br /> City, State, and Zip Code City, State , and Zip Co kv <br /> op <br /> Signature : Si natur <br /> (� <br /> i <br /> . ;� 9�� <br /> Title: F0 Caldc74 Title: <br /> Telephone: ( 7pe? 7?— Z22 Telephonecy( � � ) 7'/1YI3�Jr�` <br /> FAX: ( 2v g ) $'49- 2225 FAX: j <br /> L 1 <br /> Date: q� s7 //� 7.Ctti� <br /> 00 <br /> /� Date: <br /> E-mail: ICvrne�s�f.5� ACW3006;; e3 . Caw E-mail: cr•Ht• �` � 0 � O•fj <br /> I <br /> k <br /> wcr request-envcleanup_20060706.doc 07 July 2008 <br />