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Y <br /> r <br /> t <br /> 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 /> 901 P Street 2440 Main Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95814 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)651-0753 (530)529-7300 (559)230-3300 (81 B)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(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:I Former BP Service StationNo.443 County: San Joaquin County <br /> Street Address: 2478 East Oak Street City: Stockton <br /> Township Range and Sectionj Township 1 North,Range 6 East,Section 1 Radius:F2 miles_ <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2.miles) <br /> SECOR International Incorporated San Joaquin County Environmental Health Department <br /> Requester's Company Regulatory Agency Name <br /> Rusty Benkosky Mike Infurna <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 3017 Kilgore Road,Suite 100 600 East Main Street <br /> Address Address <br /> Rancho Cordova,CA,95670 Stockton,CA,95202 <br /> City, State, and Zip Code City, State, Zip Code <br /> Signat <br /> ure: - '' Signature: <br /> ��/� <br /> Title: Title: �T(� ✓(! _ <br /> Telephone: (F9_1_61 861-0400 Telephone: <br /> FAX: ( 916 ) 661-0430 FAX: ( ) <br /> Date: _1 ( _09 Date: .0/- <br /> E-mail: rbenkosky@secoccom E-mail: minfurna@ sjcehd.com <br /> wcr request-envcleanup_20060706.doc 07 July 2006 <br />