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SEP-17-1996 20 : 45 P . 02/02 <br /> M <br /> ATE OF IFORNI - HE RE RCE Y ARM91LD SCN RYEN ER o r <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 5 Street 2440 Main Street 3374 E. Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento, CA 05816 Red Bluff, CA 96080 Fresno, CA 93726 Glendale, CA 91203 <br /> (916) 227-1632 (530) 529-7300 (559) 230-3300 (818) 500-1645 ext. 233 <br /> (916) 227-7600(Fax) (530) 520-7322 (Fax) (559) 230.3301 (Fax) (618) 543804 (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 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 most 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: I"er r County : S _.. TC; „ <br /> StreetAddress: S15 Wtsf Cw�ti1 ?-. izva� City: Tr�64 J <br /> _Township Range and Section: Radius: V2 Hi <br /> (Include entire study area and a map that shows the area of interest.) (\l,\' (� (maximum 2 miles) <br /> I/n(�,' <br /> RequesterN Company Regulatory Agency Name <br /> st G A kLf� KJJ0L4i ) <br /> Requester's ame (please print) Agency Contact Name (please print) <br /> _2Lhcr� MM Ai� lir, �ru ; k Llo ter,y = EasF r S + rte} <br /> Address Address <br /> 711etvii� s CA rt6-67S S +-x ]- r rA q TZ 62 <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signature• _oe� Si nature: r-J (�i1LeQ <br /> Title: %,,4 Title: Rees <br /> Telephone : ( 9 l Co ) a 7 - 3il ea r% L 11 [a Telephone: <br /> FAX: ( 9 ! [. ) G707 - 3& 97 <br /> Date: "1- 17 - o "f Date: <br /> dd <br /> E-mail: - r ck a4.Lcrate � . 4M E-mail : <br /> EmmaSJc e . to . ry <br /> wcr re9ue5t-envd*anup_20060426.d0c 26 April 2066 <br /> TOTAL P . 02 <br />