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Ju 1. 18• 2005 3: 30PM Advanced GeoPvironmental No. 1348 P. 2%2 <br /> L ti.s <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 /> 32518 Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95816 Red Bluff,CA 06080 Fresno, CA 93726 Glendale,CA 91203 <br /> (916)227-7632 (530)529-7300 (559)230-3300 (818)5434600 <br /> (916)227-7600(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)543804(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT--AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/ContractNo. SaAo County <br /> T3 N, 25 � su 07 <br /> Township, Range, and Section T 3N,o-1 C Sem")3 2 t" 0- -o f- Radius <br /> r3N, izsE, 5t� . Ig <br /> (Must include entire study area and a map that shows the area of interest.) <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 (check one): <br /> Ll Make a study, or, <br /> F—j erform an environmental cleanup study associated with an unauthorized release Of a <br /> I Contaminant within a distance of 2 miles. <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 public <br /> without written authorization from the owner(s) of the well(s). The information shall be used only for <br /> the purpose of conducting the study. Copies obtained shall be stamped CONFIDENTIAL and shall <br /> be kept in a restricted file accessible only to agency staff or the authorized agent. <br /> Authorized Agent ?� Government pf Regulatory Age cy <br /> s27,n S 2 41 3n� f kk'4-c 4 <br /> Address Address <br /> �52I <br /> City, State, and Zip Code City, State, and ip Code <br /> SionatureSi naiure � s <br /> 'Alf req <br /> Title 5*q4f Cycn'oa 'S� Titler:t10't c/A4• ,7/•s Jrdr/ <br /> Telephone (Zg]) vG/off-I�n� Telephone L;bej) 7&P• J'3V50 <br /> Fax ( IoFI) NL�- M9, Fax (2&) ` 'r'(P• 3 ! �3 <br /> Date [17- )8 -C15 Date <br /> 9 f�S <br /> E-mail ' ��ao✓n4�1 adv +eenJ (n�t1_ - E_mail _,� ""'•l'� <br /> 6 June 2001 <br />