Laserfiche WebLink
STATE OF CALIFORNIA-T'HI!RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor. <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT �NORT'HERN DISTRICT SAN JOAQUIN DISTRICT SCUTI-IERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E'Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,`CA 95846 Red Bluff, CA 96050 Fresno, CA 93726 7.. Glendale, CA 91203 <br /> i (916)227-7632 T (x3()529.7300 (55 )230-33uo (518)500-1645 ext.233 <br /> (316)277-7600(Fax) (5:30)529-7322(Fax) (559)230-3301 (Fax) (818)643-4604(Fax) } <br /> WELL COMPLETION REPORT RELEASE REQUEST AND CONFIDENT,,LITY AGREEMENT',.�a <br /> REGULATORY-RELATED ENVIRONMENTAL CLEANUP STUDY �I <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 /> associated with.the unauthorized release, if the stud 'is,conducted pursuant to a <br /> an environmental cleanup stud ass Y <br /> p Y i <br /> f regulatory agency order]Water Code Section 13752). <br /> Requests must be made on the form below;signed and submitted to the appropriate DWR District Office. Please!. <br /> l 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 `3r; <br /> paper may be attached if necessary. <br /> By signing below, the requester acknowledges and agrees that, in comp€ianre with Section 13752, the � l <br /> information obtained front 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 'a� <br /> restricted fife accessible only to authorized personnel.. These reports must not be used for any purpose other_ <br /> than for the purpose ofconcl�icfing the environmental cleanup study. " = <br /> �?roject Name: t GountY: <br /> 'of <br /> ��:'�� e F mt�tii ; z <. Cit ' Ia <br /> Street Address: Y � ek�r� _ <br /> Township, Range, and Section: c tt ..mS'evb� r Radius: .2 <br /> —..... , <br /> m _ <br /> (Include entire study area and a map that shows the area of interest.) maximum 2 miles] t, <br /> 9 ._gi3� s3L 1t <br /> t :�t�cr4 �i� lrte . :. r 2���I€7ic�I <br /> Requesters Company Re ulat r Y A encyName i <br /> 'Requester's Name (pleaseprint) Agency Contact Name (pl.e�ase print) <br /> x V' <br /> �'';�� _�i1cT.�s? rf;�t"t g(C� ° - i vt?i; �.•�fY.f�?�'__ '- . <br /> Address Address =: <br /> c rt <br /> City, State, and Zip„Code City, State, and Zip Code iif max. <br /> Si nature: ` ,. l _ Signature: <br /> Title: <br /> Telephone: (, 0cl :9 Tele hone: <br /> FAX: ( } y � I.r l�( FAX: ( x•'l } IVA — d,5 <br /> L <br /> Date: 1 Fr' t'( _- -- Date: L—��icu�c.� "L CAD <br /> lt <br /> E-mail: l`Yl car i ' E-mail: r� '� S_�L•t.'nC a'n'"1 <br /> wcr request-envcleanGp_20060426.doc 26 April 2005 <br /> i <br />