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Requestor Reco nsideration (RFR) Form - N <br />� <br />r I O.For S WRCB use only. <br />NAME) <br />9iJ <br />L <br />I. FACILITY/ SITE INFORIVIATJWl BUSINESS NAME IFACILI <br />FACILITY ID# c <br />STREET ADDRES 1:11 <br />COI <br />CITY - <br />'A'l <br />ZIP 7 6 <br />EMAIL ADDRESS PHONE <br />11. N ME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br />NAME J� ©I. OWNER WA. aorH i a z <br />02.OPERATOR <br />TITLE OF APPLICANT PHONEloce <br />MAILING ADDRESS AIL G ADDRESS SAME AS FACILITY ADDRESS) .— <br />CITY <br />STATE ZIP CODE <br />EMAIL ADDRESS <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 #1 through #3, documentation is required. If you do not include required <br />documentation, your request lor 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 yoLiytf r 7 bmitted <br />with requests for reconsideration is subject to verification. ��17 I Ir <br />I. ❑ UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED.) A[!G 7 1 LU 10 <br />2. ❑ UST system(s) is exemf it from regulation, according to Section 25281(x)(1)(A)-(D) of 14\142fufdRk'a Aq TH <br />or Section 2621 of Title 23 of the California Code of Regulations. For example, certain farm ka 641hh&6&/4,6 Etqqks are <br />exempt. (DOCUMENTA ION 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 componen of the UST system. (DOCUMENTATION IS REQUIRED.) <br />❑ UST facility incorrectly located in Geotracker database. <br />❑ Public drinking water well(s) incorrectly located in Geotracker database. <br />4.PROther(explain) 5 (t <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br />III. APPLICANT SIGNATURE <br />Certification — I certify that the i*rm ation 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 ati n maybe 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 go R r <br />DATE <br />�j <br />w a n.r� i iyry mr�lLCll I DATE RF UI ST RT,CF:.fVEn <br />-- —� <br />ATE NOTIE I(ATION RFCIEVFD RLCr1VEll BY <br />