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Dear Resident November 5,2002 The following is an independent public health questionnaire to determine if any basements or municipal, domestic, or irrigation wells exist in the vicinity of Waterloo Road and Highway 99 in Stockton, California The San Joaquin County Public Health Services is requesting that we identify these features in the area as part of an ongoing environmental investigation Please fill out the following information to the best of your knowledge If you do not know, please answer "UNKNOWN' Even if there is no well or basement at the address listed, please complete items l through 5 and return the survey in the postage-paid envelope provided at your earliest convenience Should you have any questions, please contact the Cambria Environmental Technology, Inc project manager listed below This information may be submitted via mail,facsimile,or verbally by telephone Thank you for your cooperation CAMBRIA ENVIRONMENTAL TECHNOLOGY,INC Aubrey Cool Project Geologist Phone (707)933-2368 Fax (707)935-6649 P O Box 259 Sonoma,California 95476 I (1) PROPERTY ADDRESS 3�So L�ayP r-Jor� OWNER NAME DAYTIME PHONE TENANT NAME (if not owner) e rain DAYTIME PHON>3/�`L T3 _ CG (2)Are there any wells at the address listed in item 1 (circle one) . YES UNKNOWN NO (3)Are there any wells in the vicinity of the address listed in item 1 (circle one) YES UNKNOWN NO (4)Are there any abandoned wells at the address listed in item 1 (circle one) YES UNKNOWN ( NO)Z Comments (5)Are there any basements at the address listed in item 1 (circle one) YES UNKNOWN NO (6)If you answered"YES"to 2 or 3 above,please provide the following details,if possible If there is more than one well,please indicate which well you are describing WELL ADDRESS WELL OWNER WELL WATER USE FREQUENCY OF USE WELL DIAMETER WELL DEPTH WELL MATERIAL (circle one) PVC plastic steel bnck/clay other SCREENED INTERVALS)OR PUMP DEPTH DATE OF INSTALLATION • OTHER INFORMATION 1359