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STATE OF CALIFORNIA THE RESOURCES AGENCY !'ARNOLD SCHWARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> NORTHERN REGION NORTH-CENTRAL REGION SOUTH-CENTRAL REGION SOUTHERN REGION c <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 11 <br /> (530)529-7300 (916)376-9612 (659)230.3300 ' (818)500-1645 ext.233 <br /> (530)529-7322(Fax) (918)376-9676(Fax) (559)230-3301(FOX) (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 lWater Code Section 13752). <br /> Requests must be made on the form below,signed and submitted to the appropriate DWR District Office.Please J j <br /> provide the township,range,and section of the property where the study is to be conducted. Attach a map or a f <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 /> / I <br /> Project Name 76 ST�47/a-� .ya• 5fsk6 <br /> County: Ta�Qy1�/ I <br /> Street Address: Wtwj• zj&Gyt "4,6- civ: STa'kTo'r/ <br /> Township Range and section:TZ/✓ 6F s�L Z 9 Radius' 0.5 <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> 5T,4,�E� GotiS vGT%�6 Regulatory <br /> teryl�g V'j41 Lavurr �,v✓IRtry n�vr��NDN <br /> Requester's Company Agency Name FEY ( <br /> �1leWL9 l f/F&R*4 <br /> Requester's Name(please print) Agency Contact Name(please print) <br /> 3017 k1Z_61? RAO, Sy/7c lea 600 14*1' Al ! rZ* <br /> Address Address <br /> f�4tie,flO CoOkPO✓A, GA ,gs610 5-ro4r, 7o4v GA 2oi <br /> City, State, and zip Code City, State,an to 6de <br /> Signature Signature- <br /> Title: <br /> I nature•Title: SENIOR GE000el5 Title: T <br /> Telephone: (9/6 )36'/- o7YS Telephone: (Zp�L�/6 <br /> FAX: (f16 �6/-Oy30 FAX ( toy ) y6g-0/3 9 <br /> Date MrdLOy ` Date: _ <br /> ,,E-mail: bej Lzm n.a&v1o" LO 14 0fet . carr E-mail: M i nf'(/✓n a �D 5 i G8 h •Gvn <br /> vier_request_envcleahup_20090928Aoo 48 September <br /> 2009 <br /> !i/iel 9 <br />