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STATE CALIFO NIA-THE RESOURCES AGENCY ARNOLD SCHwARZENEGGER Governor <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL_DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3500 Industrial Blvd. 2440 Mairt Street 3374 E.Shields Ave Ste A7 770 Fairmont Avenue <br /> West Sacramento,CA 95691 Red Bluff,CA 96080 Fresno,CA 93726 Glendale,CA 91203 <br /> (916)376-9612 (530)529-7300 (559)230-3300 (818)500-1645 ext_233 <br /> (916)376-9676(Fax) (530)529-7322(Fax) (559)230-3301 (Fax) (818)5434604(Fax) <br /> WELL COMPLETION REPORT RELEASE REQU STAND CONFIDENTIALITY AGREEMENT <br /> REGULATORY-RELATED ENVIRO MENTAL CLEANUP STUDY <br /> Well Completion Reports associated with wells located withi i two miles of an area affected or potentially affected <br /> by a known unauthorized release of a contaminant will be m ade available upon request to any person performing <br /> an environmental cleanup study associated with the unautht dzed release, if the study is conducted pursuant to a <br /> regulatory agency order kWater 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 confide tial 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 cleanu study. <br /> Project Name;-orYvtR.1-AMe-r ica%, Tcr(,-e Sk P aa.uvj-S Coun :Sa+n _X04 u:,v` <br /> Street Address: o?�O� 1J. WeS1c L_ci City: <br /> "n N PIPE- 5e_C <br /> Townshi Range, and Section:' -:?P3 Wo I✓ sec3S Radius: o QOD Peek <br /> (Include entire study area and a map that shows the area of interest.) (maximum 2 miles) <br /> Requester's Company R gulat Agency Kame <br /> Requester's Name (please print) Agency Odntact Name (p ase print) <br /> a5-70K -Ve 'S�150 to <br /> Address Address <br /> , -� CA Qs�33 <br /> gra Int -1n►r►, 6a <br /> City, State, and Zip Code 157i , State, and Zip Code <br /> Signature: Si nature: <br /> Title: o iS Tit e: ('d Coo J', L r <br /> Telephone: 9110 671—a ail Tee hone: X 4 (as_,3 4 y 9 <br /> FAX: Qt6) t-7'?ra900 F : Ll69 - ,3V33 <br /> Date: :1`tu Iy 9, a CO3 _ Da e: Z (3 161 <br /> E-mail: V1ha VA—Ino E-r lail.. or, a a`7 5 c t �� . C.�rV- <br /> wer request envcieanu; 20090107.doe 7 January 2009 <br /> I� <br />