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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) 543-4604 (Fax) <br /> i <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 Cade 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 /> Project Name: MCBillin Property County: San Joaquin <br /> Street Address: 2154 S . EI Dorado Street, Stockton CA City. Stockton <br /> Township, Range, and Section : T1 N , R6E (Stockton West Quad ) Radius: 2500 ft <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Advanced GeoEnvironmental , Inc. San Joaquin County Env. Health Dept. <br /> Requester's Company Regulatory Agency Name <br /> Tim Cuellary i t: j{ 1 Me, ( * r+ n e y <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 837 Shaw Road 1SL8 5 , VAaz. elton Ave . <br /> Address Address <br /> Stockton , CA 6- +0 ck+0 n _ CA 9 5 2 0 5 <br /> City, State, and Zip Code City, State, and Zip Code <br /> (fir <br /> Signature: Si nature: 1 <br /> Title: Project Manager Title: Se ' r e i seer vi rnen+0. � <br /> Ke 1 +Irt spec;alisfi <br /> Telephone: ( 209 ) 467-1006 Telephone: ( 209 ) 46 8 - 48 S Z <br /> FAx: ( 209 ) 467- 1118 FAX: ( 209 ) 46 8 - 0 34 1 <br /> Date: 09/17/2014 Date: O 9 I 117 /. 2 0 14 <br /> E-mail: tcuellar@advgeoenv. com E-mail: V McGQr' I1ney @ 5ic� ehal co rn <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br />