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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 (Water 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: COUNMY MMzlCET County: &4N at tl VIN <br /> Street Address: 1044.6 W. WINE ROA- City: RACY <br /> sera 1 <br /> Township, Range, and Section: T.0 RS E 9 ( Wrap / Radius: 0 • 25 mGICS <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> AN7sA C7 ,eoutp San God Enylrmenlor flee tl?1 AepE. <br /> Requester's Company Regulatory Agency Name <br /> NlatF PERCAVI Vl?k! 14kCArI-he9r <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 1155 N I=l2Sr ST SW7E 2pl /8f68 leas+ Relgam 7n Avg <br /> Address Address <br /> S" JOSE CA ,95112 StfoalcfvD cR g5z0S <br /> City, State, and Zip Code City, State, and Zip Code <br /> Signatur S. Signature: `7/ soi� _ <br /> i <br /> Title: P � Mh1JAC V9L Title: Sen o r R r E . 14 <br /> Telephone: ( 4q ) X58 - 30-t Telephone: ( 209 ) 9852 <br /> FAX: ( yZ5 ) 816 -9830 FAX: ( a0 4 )_ q (o g - 034 <br /> \ <br /> Date: (e ? Date: 1? S/IF <br /> 7 � <br /> E-mail: Y) IGOk . persavd&ak)" ryup, tmvh E-mail: ✓n1G�Ar�nGy@SlGeltd. �a ✓Y7 <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br />