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JRN-26-2003(SUN) 17; 12 P. 002/003 <br /> SIe1MOESr!°ILIICDRI A-YMrE RESOURCES AGENCY Govermw <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOACIUIN DISTRICT SOUTHERN DISTRICT <br /> 901 P Street 2 540 Main Street 3374 S,Shields Ave Ste A7 770 Fairmont Avenue <br /> Sacramento,CA 95814 Red Bluff.CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (918)651.0753 (530)S29-7300 (559)2''10~1'300 [818)500-1645 c4 233. <br /> (916)851.0725(Fail (530)529.7=(Fax) (559)230-3301 (Fax) (8718)543.4544(Fax) <br /> WELL COMPLETION REPORT RELEASE REQUEST AND CONRDENTIALITYAGREEMENT <br /> REGULATORY-RELATED ENVIRONMENTAL CLEANUP STUDY <br /> Well Completion Reports associated with wells located within two miles of an area affected or potentially aftected <br /> by a known unauthorized release of a contaminant will be made available upon request to any person peftrming <br /> an environmental clearsup study associated with the unauthorized release,If the study is conducted pursuant to a <br /> regulatory agency order oNater 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 infomlation.requested below as possible,-additional <br /> paper may be attached If necessary. <br /> By signing Wow,the requester acknowledges and agrees that.In compliance with Sectlon 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 deanup study. <br /> Project Name: 04_Iw44'1- ; m gr-�rJ leer 114,4 d County, Scz1 <br /> Street Address. [ � W 12O #ate City. -5- <br /> Townshle, Range, and Section: '"r2 A.1 R S Radius: M r <br /> (Include entire study area and a map that shows the area of Interest.) (maximum 2 mllas) <br /> 3i{ePLI/ Nur. _ .L'f -cUZritJf,. ��-rs_ Jod ca.,u Ifo. &l"dea. 0404 <br /> Reque tar's Company Gto 1U4-1- Regulatory Aoncy Name ylev /tti Deaf <br /> Request is Name(pleaseprint) Agency Contact Name (please print) <br /> Address <br /> nr Address <br /> -/-0 AJ CA 45->C)a-RD <br /> City, State, and Zip Code City, State, and Zip Code <br /> Si nature: Signature: (67A-1,6)JA- r <br /> Title• opehv r•;>0-d Titie. c <br /> Telephone: (2D9 ).--36C/7 17Z Z 1 Telephone: 033 7 <br /> PAX: (.2O 9)3&1? <br /> --—— FAX: (, <br /> Date: /4 Date: � �j f LD F{ <br /> E-mail: S�rrU ruryi e Fa c 1� �. E-mail, to U rcw U 05NT,LC-e„LA_ c o e vi <br />