Laserfiche WebLink
STATE OF CALIFORNIA-THE RESOURCES AGENCY <br /> 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 (818)500-1645 ext_233 <br /> (916)651.0726(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)543-4664(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: Kerlinger Aggregate Plant County: San Joaquin <br /> Street Address: 30350 Tracy Blvd. �o City. Tracy <br /> Township, Range and Section: T3S, R5E, 16 �_f►?0 -l2( -T}c4 2Radius: 2000 feet <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> SOMA Environmental Engineering San Joaquin County Env. Health Dept, <br /> Requester's Company Regulatory Agency Name <br /> Erica Fisker, Ph.D. Harlin Knoll, REHS <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> 6620 Owens Drive, Suite A <br /> 600 E. Main Street _ <br /> Address _ Address <br /> Pleasanton, CA 94588 Stockton, CA 95202-3029 <br /> City, State, and Zip Code City, State, and Zip Code �/ l <br /> S;gnature <br /> Title: Senior Staff Geologist Title: Senior Registered Environmental Health Specialist <br /> Telephone: (925 )734-6400 Telephone: ( 209 )468-3442 <br /> FAX: ( 925) 734-6401 FAX: ( 209 ) 468-3433 <br /> Date: 4/26/2011 Date: Y1,2 <br /> E-mail: efisker@somaenv.com E-mail: hknoll@sjcehd.com <br /> wcr request-envcleanup_20060706.doc 07 July 2006 <br />