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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 iWater 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: J oYwrA^ ge✓✓'oh �V&c S�a o� 2z� County: <br /> Street Address: ��12 Nr f� �Jwl rcr !jt-eeCity: 9U-1411 U <br /> Township, Range, and Section: �PNG. 39 z59 05 Radius: <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> koa-,, a.es. I 1C. �� <br /> Requester's Company Regulatory Ag cyy�Na��me <br /> �GLvtneron Ot 6tloilpefiil G- ��C /v(�Gt7/7^ <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Address Address <br /> F&IsoW (Xi Lc�Yl <br /> City, State, and Zip C de City, State, a Zip Code <br /> Si nature: 114�l / Sin re: <br /> Title: F),V1'0,*;,M��ac l 5pjenrr�� Title <br /> Telephone: ( 916 ) q$5 2p71 X 24 Telephone: <br /> FAX: 1.0q_i FAX: <br /> Date: ��/Q�// Date: <br /> E-mail: �' ,e✓eh , w�c4o►rP✓K E-mail: Ll't ajina 1IGPNaI• Cor+, <br /> N'caj us,LDvti. <br /> wcr_request_envcleanup_20110518.doc 18 May 2011 <br />