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tdl�t� <br /> rSTATE OF CALIFORNIA-THE NATURAL RESOURCES AGENCY EDMUND G.BROWN JR Governor <br /> G.P 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(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: 1�t�l q�f - 5�0<�r+h� County: Je,n ,�Ct (�1-1 In <br /> Street Address: ?0) + `A)/��f ��/ City: ,�9`0c ¢�rl <br /> Township, Range, and Section: �:; AZ.- Radius: /" A <br /> (Include entire study area and a map that shows the area of interest.) -� (maximum 2 miles) <br /> c�(-,4 n o A-�G J 6 w. ' : 114 b <br /> Requester's Company Regulatory Ag cy Name <br /> J o h O SO_,/14,n a v\ NA KL 1 <br /> Requester's Name (please print) Agency Contact Name (please print) <br /> Address Address <br /> M ,/'Aes� <�,to C)<_+,*�, CA <br /> City, State, and Zip Code City, Stat"adZip Code / <br /> Signature: Si nature <br /> Title: S�G�^F- V_o/04 16 Title: w- ® � <br /> Telephone: (g C9 ) S7 Telephone: ( &-J) V 6,F- <br /> FAX: (�07) SJ-? r! 22,?. S_ _ _ FAX (59) Y W -6 3 cf 1 <br /> Date: ('J G-(-. 1 I A G{3 Date: 10//�;-/2 D l? <br /> E-mail: �n.Se`/,,1Gr)(.9- Cb{ <br /> (a rI) o,Com. E-mail: Il CV <br /> wcr_request_envclearwp_20110518.doc 18 Mav 2011 <br />