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• s <br /> . -EO'd _1U101 <br /> STATE OF CALIFORNIA-THE RESOURCES AGENCY ARNOLD SCHW RZENEGt3ER,GOvornor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 901 P Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95814 Red Bluff,CA 96050 Fresno,CA 93726. Glendale,CA 91203 <br /> (916)651.0753 (530)529-7300 (559)230-3300 (818)500-1645 ext.233 <br /> (916)651-0726(Fax) (530)529-7322(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 /> 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: vc 121-an �r,.reh ac.tG� v„ b(,-r1iCounty: <br /> SGvI L�cr��ivti <br /> Street Address: <br /> Township, Range. and Section: "� 1,7 :2 r(_Vq ��k ( rhi C�u�� Radius 2v�o <br /> (include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> riS(� <br /> Requester's Company Regulatory Agency Name <br /> kp�5 _ Cllfn i1!na�� <br /> Requester's Name (please/print) Agency Contact Name (please print) <br /> 1041'( (J)A (I�c[?!va�l�lGc:�� 5111 ✓'7v 660 r"4 po'.n 311-cee-f <br /> Address Address( n <br /> City, State, and Zip Code City, <br /> City, State, and Zip Code <br /> Signature: Gam' Signaturejo._� '( _ _ <br /> Title: Si �'! Title: <br /> Telephone: 0116 ) 2$8 - 1-{�6S T TeIeph0ne:1 yds 7.-1.11 ---- <br /> FAX: 76 L— 8 rvU FAX: 2,013 <br /> Date: -7 Date: ?-2 7 <br /> �0 ` <br /> E-mail: !'I/1 c�PPS & i+'n5f�• [\l2Cr1y.-�am E-mail: hkAP � s I � IZ/ d py_ <br /> wcr request-enveleanup_20060706.doc 07 July 2006 <br /> Z0'd 0028 E92 9T6 OOZE) E92 9T6 ZS:OT LOOz—SZ—�flf <br />