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STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER.Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3500 Industrial Blvd. 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> West Sacramento,CA 95691 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)376-9612 (530)529-7300 (559)230-3300 (818)500-1645 ext.233 <br /> (9 16)376-9676(Fax) (530)529-7322(Fax) (559)230-3301(Fax) (818)543-4604(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 jWater 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 /> Project Name: Fo`ye-A County: S­ Jo�9y>1� <br /> Street Address: <br /> ln/es} leve S �yccy , C� City: I <br /> Township, Range, and Section: T 2 :5 C Seek"ZZ Radius: 7,000 <br /> (Include entire study area and a map that shows the area of interests) (maximum 2 miles) <br /> /STC_ / 5-5-0c I aJe S .Sc.�. Joa.t��r. Co. Eny4oame,&X 14ea.f ,g Qeof: <br /> Requester's Company Regulatory Agency Name <br /> i IL/" v ,j,-i- MCA.-.l 14ChcJerae h <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> ► i t� L��� P,1-, Ave-,c �vJL 7-of GoD F / A"6. Yf <br /> Address Address <br /> 1,4,<J(_? C A �5 3S l .SIW kk 114 ,gS2o 2 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature: mature://%s �%✓ ✓ C_" <br /> Title: Sia tf c-'e"1 o c j S+ Title <br /> Telephone: (Zoq ) 5 - Z2.zi Telephone: (709 <br /> FAX: ( 2ja ) 5 7q -2-2-2,5 FAX: (?,99 } yG ff- <br /> Date: qy s� zo ocl Date: 9 <br /> E-mail: de -4 54 (-) 11+CA5SaG(lie3,eoL�, E-mail: nheNjerSOh@S14eCel <br /> wcr request_envcleanup_20090107.doc 7 January 2009 <br />