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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: 1,% 010`7S County: SG^ T:� <br /> Street Address: 3 9 7 5�.,E� 1-f„I, {,� q City: 's <br /> Township, Range, and Section: I ZN, /L rw SFC 2.`f Radius: <br /> (Include entire study area and a map that shows the area of in rest.) (maximum 2 miles) <br /> A tZ C4 DSS 51- <br /> Requester's <br /> Requester'sCom' !p/any Regulatory A yenc4y Nam <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Address Address <br /> Cats » CA CA c) S-7. <br /> City, State, and Zip Coe City, State, d Zip Co <br /> Signature: Si tures , <br /> Title: Title: <br /> Telephone: ( `�I� ) �?s�S —2.,57 t I y Telephone: (0701) <br /> FAX: qiG} k ' - �.o FAX: (,R6,4; <br /> Date: Date: a� 07z 70/oq <br /> E-mail: 42 cirrtc(iS - us.c,,,, E-mail: <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br />