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I <br /> f ARNOLD SC WARZENEGGER.Govern <br /> STATE O CALIFORNIA THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES <br /> SOUTHERN REGION <br /> NORTHERN REGION NORTH-CENTRAL REGION SOUTH-CENTRAL REGION <br /> 2440 Main Street 3500 Industrial Blvd. 3374 E.Shields Ave Ste A7 770 Glendale,Fairmont <br /> Avenue <br /> 91203 <br /> Red Bluff,CA 96080 West Sacramento,CA 95691 Fresno,CA 93726233 <br /> ,i (530)529-7300 (916)376-9612 (559)230.3300 (818)500-1645 ext. ) <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 /> II; 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: Beacon Skakjun 0a 3&A County: 50A 300LJ" <br /> Street Address: JIM EaS4, "okM *.r L-art2 City: SOGIGLon <br /> Township,-Ran e, and Section: ITT 1 Mae, SQL 6V%S IN t!is Radius: t/L— tte <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles).. <br /> Nort>zan 604"nmen6A Tnc. San UkAA�tn Cot,&At. Eno��ytrnwtka I'laestA�. <br /> Requester's Company Regulatory Agency Name <br /> %ran S ht Nr. "10%40A TAGArna. <br /> Requester's Name (Please print) Agency Contact Name (please print) <br /> ta&AAQkg.lt. DeWP_ SK;4e CIS (060 Erik ka:l t SAr2e.k <br /> Address —�-� Address <br /> El Oorp cto W tkS . c.A AS'4f02 Skoak yon CA a52oZ-soul <br /> City, State, and Zip Coe City, State, d Z' Code <br /> rt Signature: Signature, <br /> Title: S+a.Ff 41.t droaeoloa:ck Title: <br /> Telephone: (Alb ) A3q-21-40 Telephone: ( 4909) <br /> ;4. <br /> FAX (alb ) gS01 -2t_-7- FAX: ( ) <br /> Date: h I►5 It o Date: /✓O k,1- TSS ZO>O <br /> I E-mail E-mail: <br /> ��, wcr requesl_envcleanup_20090928.doc 28 September <br /> 2009 <br /> .. .,.. �_.,.: -. ;N" .. .-,. » d41' .w,s , e.-+ix.'. :,t.a ,1. .. ,F .• .i�.. .r .,. <br />