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Request for Reconsideration Form <br /> I. tFACILPTY/SITE INFORMATION <br /> BUSINESS�JAME c� urv, ,N �6�S 1 �� FACILITY ID# - � '' <br /> STREET ADDRESS U W PHON <br /> CITYCOUNTY ZIP CODE <br /> LOff\ -c1iv\_b �2r4 a <br /> H. NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br /> ,tp <br /> N 1.OWNER <br /> LU T 1 2.OPERATOR !_. <br /> TITLE OF APPLICA - -�-�— PHONE <br /> MAILING ADDRESSMAILING ADDRESS SAME AS FACILITY ADDRESS) <br /> CITY STATE ZIP CODE <br /> Please check reason(s) why you believe that the California State Water Resources Control Board(SWRCB)notification is in error. If <br /> you are requesting reconsideration for reasons #2 through #4, documentation is required. IF YOU DO NOT INCLUDE <br /> REQUIRED DOCUMENTATION, YOUR REQUEST FOR RECONSIDERATION APPLICATION WILL BE <br /> CONSIDERED INCOMPLETE AND WILL BE RETURNED. INCLUDE ALL SUPPORTING DOCLIIENTATION YOU <br /> WISH THE SWRCB TO CONSIDER WHEN REVIEWING YOUR REQUEST. REQUESTS FOR RECONSIDERATION <br /> ARE SUBJECT TO VERIFICATION. <br /> 1. ( )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 systein(s)present. <br /> 2. ( )UST system(s)is permanently closed. (DOCUMENTATION IS REQUIRED) <br /> 3. ( )UST system(s)is exempt from regulation,according to Section 25281(x)(1)(A)-(D)of the Health and Safety Code,or <br /> Section 2621 of Title 23 of the California Code of Regulations.For example, certain farm tanks and heatins_oil tanks are exempt. <br /> (DOCUMENTATION IS REQUIRED) <br /> 4. (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 1,000 <br /> feet from a public drinking water well, include a demonstration that the well head is more than 1,000 feet from the closest <br /> 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 /> 5. ( )Other(explain) <br /> NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <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 based on false or <br /> misleading information may be considered a violation of Health and Safety Code,Section 25299, punishable by flue up to$5000. <br /> NAME OF APPLICANT(print) PHONE <br /> SIGNATU F A `DATE <br /> FOR AGENCY USE ONLY <br /> DATE NOTIFICATION MAILED DATE REQUEST RECEIVED DATE DECISION DUE DATE OF DECISION NOTIFICATION <br /> DATE NOTIFICATION RECIEVED RECEIVED BY DATE OF DIVISION DECISION REQUEST APPROVED <br /> :REQUEST DENIED <br />