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05!1812004 17:18 2094671"-� - AGE STOCKTON PAGE 02/03 <br /> \_/ %R . <br /> STATS OF C.AQFGRNIA.-__THE RESOURCES AGENCY ARNOLo C ARZENEGGER Govern <br /> DEPARTMENT OF WATER RESOURCES <br /> CENTRAL DISTRICT NORTHERN DISTRICT SAN JOAQUIN DISTRICT SOUTHERN DISTRICT <br /> 3251 S Street 2440 Main Street 3374 East Shields Avenue 770 Fairmont Avenue <br /> Sacramento,CA 95815 Red Bluff,CA 96080 Fresno,CA 93726 Glendale.CA 91203 <br /> (916)227.7632 (5$Q).529-7300 (559)2.30-3300 (81e)543-4600 <br /> (916)227-7600(Fax) (530)$297322(Fax) (559)2303301(Fax) (818)!543-4$04(Fax) <br /> WELL COMPLETION REPORT RELEASE AGREEMENT,AGENCY <br /> (Government and Regulatory Agencies and their Authorized Agents) <br /> Project/Contract No, f r�Q t A _ County <br /> Township, Range, and Section G f I Radius <br /> ;�.,.. <br /> (Must include enfire 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 /> Make a study, or, <br /> Perform an environmental cleanup study associated with an unauthorized release of a <br /> 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 infprmation 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 o e&Iato A c <br /> rY Y <br /> � � � <br /> Address Address <br /> City, State, and Zip Code Cgo City, State, and ZipiCode <br /> Si nat re Si nature <br /> A Wv%� <br /> /01 <br /> Title I J.. Title Jd <br /> Telephone 65 �21 3"�A �y Tele hone dV I .� <br /> Fax,. ( (off-) �2� : �c1 Fax <br /> Date �p <br /> Date <br /> E-mail 60 4 E-mail <br /> SJCE cd <br /> 6 June 2001 <br />