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0 0 FMCEIVED <br />Request for Reconsideration Formffl$ar�otiq, .IauuuNly <br />I. FACILITY/ SITE INFORMATION <br />BUSINESS NAME (FACILITY NAME) FACILITY ID# i { <br />F...�.v cue 3,-7 r✓'_ � i <br />STREET ADDRESS ,PHONE <br />CITY COUNTY ZIP CODE <br />TfgG y-'IL,tr% -7 <br />_ II. NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br />NAME --- -----' -r191. OWNER A,gC+! — ---- <br />i i ❑ 2. OPERATOR <br />TITLE OF APPLICANT PHONE <br />. ..-.. -- _ .. — ( )�__... <br />MAILING ADDRESS ❑ (MAILING ADDRE AS FACILITY ADDRESS) <br />......... ....... .__ ------ <br />CITY ' STATE ZIP CODE <br />i FG r i cX �3Z3C� <br />Please check reason(s) why you believe that the California State Water Resources Control Board (SWRCB) notification is <br />in error. If you are requesting reconsiderafion for reasons #2 through #4, documentation is required. IF YOU DO NOT <br />INCLUDE REQUIRED DOCUMENTATION, YOUR REQUEST FOR RECONSIDERATION APPLICATION WILL BE <br />CONSIDERED INCOMPLETE AND WILL BE RETURNED. INCLUDE ALL SUPPORTING DOCUMENTATION YOU <br />WISH THE SWRCB TO CONSIDER WHEN REVIEWING YOUR REQUEST. REQUESTS FOR RECONSIDERATION <br />ARE SUBJECT TO VERIFICATION. <br />( ) I am not the owner or operator of a UST system. Check applicable reason: <br />( ) Change of owner or operator. (Provide name and address of new owner/operator, if known) <br />( ) No UST system(s) present. <br />( ) UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED) <br />( ) 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 />(K) Closest component of UST system(s) is greater than 1,000 feet from well head of any public drinking water well. <br />Check applicable reason(s): If the request for reconsideration is based on evidence that the UST system in question is <br />greater than 1,000 feet from a public drinking water well, include a demonstration that the well head is more than 1,000 <br />feet from the closest component of the UST system. (DOCUMENTATION IS REQUIRED) <br />( ) UST facility incorrectly located in GeoTracker database <br />( PublicDrinking Water Well(s) incorrectly located in GeoTracker database <br />( ) Other (explain) <br />III. APPLICANT SIGNATURE <br />Certification - I certify that the Information provided herein Is true and accurate to the best of my knowledge. Knowingly submitting a request for reconsideration <br />based on false or misleading Information may be considered a violation of Health and Safety Code, Section 25299 punishable by fine up to $5000. <br />AME <br />NOF APPLI T (print) PHONE <br />(�_ab.—_� <br />SIGNAT F PLICAN r _ DATE <br />11 5 o4 <br />t3t�-STq • 2.r� <br />FOR AGENCY USE ONLY <br />DATE NOTIFICATION MAILED DATE REQUEST RECEIVED DATE DECISION DUE DATE OF DECISION NOTIFICATION <br />DATE NOTIFICATION RELIEVED RECEIVED BY DATE OF DIVISION DECISION REQUEST APPROVED <br />REQUEST <br />�i a l <br />� ' bio' <br />i <br />G o u <br />DENIED <br />DENIED <br />