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Request or ReconsiderationR Form <br />c� ) <br />BUSINESS NAME (FACIE NAME) <br />c� FACILITY ID# <br />STREET ADDRES <br />CITY <br />EMAIL ADDRESS <br />6Z) UA <br />ERATOR Sl <br />NAME A <br />TITLE OF APPLICANT <br />MAILING ADDRESS MAIL , G ADDRESS SAME AS FACILITY ADDRESS) <br />CITY <br />EMAIL ADDRESS <br />RFR NO. <br />For S WRCB use only. <br />T/7 <br />court �,ON! <br />.rl <br />ZIP '? S 76 E"3PHONE' <br />(") <br />TTING REQUEST <br />0 I. OWNER BOTH I & 2 <br />2. OPERATOR <br />PHONE <br />kw 9--�' r---? 4L r� <br />STATE I ZIP CODE <br />Please check reason(s) why you believe that the California State Water Resources Control Board (State Water Board) notification is in <br />error. If you are requesting reconsideration for reasons 41 through #3, documentation is required. If you do not include required <br />documentation, your request for reconsideration application will be considered incomplete and will be returned. Include all <br />supporting documentation you wish the State Water Board to consider when reviewing your request. All information submitted <br />with requests for reconsiderat on is subject to verification. <br />1. ❑ UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED.) <br />2. ❑ UST system(s) is exempt from regulation, according to Section 25281 (x)(1)(A)-(D) of the Health and Safety Code, <br />or Section 2621 of Title 23 of the California Code of Regulations. For example, certain farm tanks and heating oil tanks are <br />exempt. (DOCUMENTATION IS REQUIRED.) <br />3. [] Closest component of UST system(s) is greater than 1,000 feet from well head of any public drinking water well. Check <br />applicable reason(s): If the request for reconsideration is based on evidence that the UST system in question is greater than <br />1,000 feet from a public dr nking water well, include a demonstration that the well head is more than 1,000 feet <br />from the closest component of the UST system. (DOCUMENTATION IS REQUIRED.) <br />❑ UST facility incorrec ly located in Geotracker database. <br />❑ Public drinking watei well(s) incorrectly located in Geotracker database. <br />4.O(explain)�� �(rOtc <br />,r.— � <br />% 'KY -- rs <br />C:. <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br />Certification — I certify that the in rmation provided herein is true and accurate to the best of my knowledge. Knowingly submitting a request for reconsideration <br />based on false or misleading infor ate n may be considered a violation of Health and Safety Code, Section 25299, punishable by fine up to $5000. <br />NAME OF APPLICANT (print) <br />PHONE� <br />SIGNATURE OF APPLICANT <br />�f DATE <br />YORfiWRCI3ITSF OVI Y <br />DATE NOTTFTCATT,')N MAI1,1 I� tILAJ RT LtF�T i(�( F.IVi <br />DATI: NOTTFI('AN RFCFI� R@CF 1VED SY <br />