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� �o LUVJ�JUIY/ 10• J4 <br /> • . P 002/003 <br /> STAT['OF Ge11F0RMA- "'va OURCES AC N <br /> uEPARTMENTOF WATER R�AVVKl,t.S ARVOLDSCIIWA FNFCCFa Goo»or <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT <br /> 901 P Strout 2440 Main Street 3374 E.Shields Ave Ste A7 77 F SOUTHERN DISTRICT <br /> Sacramento, CA 95814 Red Bluff,CA 96080 Fresno,CA 93726 <br /> (918)651-0753 (530)r�-7300 Glendale,CA 91203 <br /> (016)651-0728 Fox (530)529.73II Fnx (559)230.300 $00-1645 ext. <br /> (Fox) ( ) (559)230.3301 (Fez) (818)5543 46044(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: </ lir P s 1AJ County: <br /> t 1 Tnn <br /> Street Address:,2? <br /> c <br /> Township, Range, and Secfion f p2�/ �� _`C��" Radius: (A i /pS <br /> (Include entire study area and a map that shows the area of Interest.) (maximum 2 miles) <br /> _S-{-c'��ir.✓ �-, . /1-�u�° CoNsvmN 6- 5i(-�/ ?"oa u�r� fou �n u r�awr�re'r�.� <br /> Requester's Company o-Zc76 a i Regulatory Agency Name <br /> DP�f- <br /> Requester sName (please print) Agency Contact Name (please rint) <br /> PO r3o �S`Z pp <br /> O S-IL N1411 A) V,"e'' <br /> Address �-1 r'rlc f n ^i n cLcc?�o? 0 2 y <br /> r� /f Address <br /> itJQ:JrJ�/'i4' S-a<p_��C' •7<oi✓ gS002'.302� <br /> Ciry, State, an Zip Code City, State, and Zip Code <br /> Sl nature 2 G Signature:- <br /> Title: ��„v�, r�.oC Title: T— <br /> Telephone: Q0 9 ) 36 9 cl 4t2/ Telephone: (209 ) <br /> FAX: (,209 ) 3& 9- 93 S- S FAX: xo - 6 y3 <br /> Date: l�i n /n It Date: G <br /> E-mail:5-F u 56Co/a&A ee7(- E-mail: n��� r�o/' Ceh4j. Cdr+1 <br />