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0 0 <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NORTH-CENTRAL REGION SIXTH-CENTRAL REGION SOUTHERN REGION <br /> 2440 Main Street 3500 Industrial Blvd. 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Red Bluff,CA 96060 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;addidonal <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 inspecdon 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: rORA40X V , 10. 6 y gl County: ,4,4X/ 70,4 6?VI t/ <br /> Street Address: 1-/707 A�/614- AL/eAV4- city: jTOeK-row' <br /> _Township, Range, and Section: T Z/y S6,--- SSG Z $ Radius: 0, 5 <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> C,r}.t/ J 0 h 60vwrY <br /> 5T�v7�G lov5r/r,T/NG Ek1✓tKavAtF.vrfv- /1x44-r# - <br /> Requester's Company Regulatory Agency Name <br /> Requester's Name (please print) Agency Contact Name(please print) <br /> 30 17 ff/G 6090� ED42 5411 72F-/CO 1400 y7" rt�l v yrRt�'i" <br /> Address Address <br /> /1,4&614 0 150112yroGK7��; Gf� 95 Z- <br /> City, State, and Zip Code City, State, and Zip Code <br /> SignatuSignature: (&L& <br /> Title: Sh41106 AE04_06157_ Title: Semhtn ke" <br /> Telephone: (J& ) J'$-4/-074/.5 Telephone: (7-0q) %�--03,,37 <br /> FAX: ( 17/6 ) 60-04/30 FAX: (2JP? ) y6H—013$ <br /> Dat /eoq t Date: <br /> E-mail:tcnjamin. Ghe✓1p, �>)fc. coon E-mail: ��Uh GG n r4 5 i Ge h d . CpM <br /> war request_envcleanup_20090928.doc 28 September <br /> 2009 <br />