Laserfiche WebLink
STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHWARZENEGGER,Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 E. Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento, CA 95816 Red Bluff,CA 96080 Fresno,CA 93726 Glendale, CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230.3300 (818)500-1645 ext.233 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)5434604(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 /> 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:C,t}u F'aAn S ree{ County: 'fin �)wod�;Yl <br /> Street Address: (_001 FGiS-F Mrt;v, S+rae+ City: 11T -t-cn <br /> Township Range, and Section: T-IN� 1Z6E Radius: 2 UCO P4 <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Adyanccd Ge0EnkAYCYlt 0nAa(, Inc . t <br /> Requester's Company Regulatory Mency Name eC",jyrN *70CA-j <br /> Reheeeu E. Nt cd �4*fL <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 83'I thaw '2C)Ck8 ( a0 Ects "aa" 3hyfe+ <br /> Address Address <br /> SbCWon fCA CS21S SkDc� O2 _ <br /> City, State, and Zip Code <br /> City, State, and Zi C d <br /> Signature: /(tom/ Si nature: <br /> Title: k_CZF 2>'(InIF14 Title: <br /> Telephone: (2p9)Qj-7- (pQ(y Telephone: ( ,W?) <br /> FAX: FAX: <br /> Date: / (( J 1 I Date: Zai <br /> �7, Zai <br /> E-mail: E-mail: /.✓M'/�e.�A � SJC�i�fs�. [ort <br /> wcr request-envc1eanup_20060426.4loc 26 April 2006 <br />