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Request or Reconsideration (RFR) Form RFR NO. <br /> For S WRCB use only. <br /> 1 FACILITY J'SI3 E <br /> BUSINESS NAME[FAclu NAME) <br /> TION <br /> �- n FACILITY D:)#STREET ADDRES <br /> CITY TP <br /> ZIP <br /> EMAIL ADDRESS <br /> HONE <br /> NAME /j�� -. %NUTTING REQUEST _ <br /> rnI.OWNER BOTH I&2 <br /> TITLE OF APPLICANT D2.OPE RATOR <br /> PHONE <br /> MAILING ADDRESS <br /> MAiL G ADDRESS SAME AS FACILrrY 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 reco sideration for reasons#1 through#3,documentation is required.If you do not include required <br /> documentation,your request r reconsideration application will be considered incomplete and will be returned.Include all <br /> supporting documentation yo 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 /> I- ❑UST system(s)is perm ently closed.(DOCUMENTATION IS REQUIRED.) <br /> 2• ❑UST system(s)is exem t from regulation,according to Section 25281(x)(1)(A)-(D)of the Health and Safety Code, <br /> or Section 2621 of Title 2 of the California Code of Regulations.For example,certain farm tanks and heating oil tanks are <br /> exempt.(DOCUMENTA ION IS REQUIRED.) <br /> 3• ❑Closest component of T 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 incorrec ly located in Geotracker database. <br /> ❑Public drinking watei well(s)incorrectly located in Geotracker database. <br /> 4. �ZOther(explain) <br /> NOT :SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br /> Certification—I certify that the in r tion 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 may be considered a violation of Health and Safety Code,Section 25299,punishable by fine up to$5000. <br /> NAME OF APPLICANT(print) 4 onsideration <br /> PHONE <br /> SIGNATURE OF APPLICANT Q��r- r <br /> �f DATE f/ r <br /> x'OT2 B �RCB ITSF ONLY <br /> DAT-�NO..;riFl ATIO MA If GL7 D1TEK£( L!E' TRECF;IVIj <br /> DATE E NOTIFICATION RF(-,VE, RCChIy E <br />