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`wo, s4=001 <br /> 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 /> 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: 1/�oor`C. pc�ro/cv.+� �3u/k elf County: <br /> Street Address: / S ad City: 730eV1---.- <br /> Township, Range, and Section: Z SC W ZZ__ Radius: Z, 0,0 C.) 4 <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> 11 pt K F,Un-o/ev�/_7; cC <wz Tnaj�,4n Cw67 lrvu Alea l-4 bepf <br /> Requester's Company f Regulatory Agency Name <br /> I C�o.L.( (.14w C�t✓l Gr�.a/G v1 Ur,ek" IAC.4 y4 <br /> Requester's Name (please print) Agency Contact Name (please rint) <br /> 11 Lcf(-1 Py��k s ca�.,� l no Y �ari� Ha�L/,41n •mac. <br /> Address/ n CPQ <br /> Address ` /1 <br /> Cc <br /> 70 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Si nature: r / Si nature: <br /> Title: Ptoject C.�Cy/o5,,T4 Title:�lir:e/�nN�a.�w�•-r�, <br /> Telephone: (1/&) $57 - 01-7 c{ Telephone: (Z�4? y(p <br /> FAX: (c7/ " 6 t 7`7 FAX: ( .2o 9 ) 4(, <br /> Date: ! / 2- Date: q/// / 12— <br /> E-mail: <br /> ZE-mail: !^��kcV�aptix�nv,�d>�c��,. car• E-mail: Vfn,-Gar+-n e ti S Geho( •coni <br /> wcr request_envcleanup_20110518.doc 18 May 2011 <br />