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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) (9 16)376-9676(Fax) (559)230-3301 (Fax) (618)5434604(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT-AGENCY STUDY <br /> (Government Agencies and their Authorized Agents) <br /> Under California Water Code Section 13752, the agency named below requests permission from <br /> Department of Water Resources to inspect or copy,.or for our authorized agent named below to <br /> inspect or copy, Well Completion Reports filed pursuant to Section 13751 to make a study. <br /> In accordance with Section 13752, information obtained from these reports shall be kept <br /> confidential and shall not be disseminated, published, or made available for inspection by the <br /> public. The information shall be used only for the purpose of conducting.the study. Copies <br /> obtained shall be stamped CONFIDENTIAL and shall be kept in a restricted file accessible only to <br /> agency staff or the authorized agent for this study. <br /> j Project Name: F �2�pOtV f�QSE�1 SttN(L�S _ t�� CountY: Qg111a <br /> Street Address: �1 .Sl���� ��SaC I��� ANIVAVI City: �A%N <br /> Township, Range, and Section-72-S, 10 19k. .Sb Radius: 2� T <br /> (Include entire study area and a map that shows the area of int ,est.) <br /> So�v.Sc etLAtL"C-cvLA, ' 7 <br /> VCMLL1` ®+- �,`►C: IVtYctwruev� 4Cai' u( fct4 <br /> Authorized Agent Company Name Government Agency Name <br /> Address Address <br /> C'Ea �� h t <br /> City, State, and Zip Code City, State, and Zip Code <br /> Authorized Agent Name (please print) Agency Contact Name (please print) <br /> 1 <br /> Signature r Signature:w <br /> Title: _S 1�110(L [� �LBC�\ ` _ -- Title: Sv.4l.cOr <br /> Telephone. — [ Telephone: (ao"T ) <br /> FAX: ) �"'� ��11 FAX: (01 ? 6g-.3"13 3 <br /> Date: 3` 2-A II Date:- <br /> E-mail: <br /> aterE-mail: E=mail: a Cv <br /> wrr ranueei ertrxnraalnriv 7fL�iRgiR.tnr <br /> 4e RA— fne <br />