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RFR NO. <br /> Request for Ree .,,sideration (RFR) Form For SWRCB use only. <br /> I. FACILITY iii—INFORMATION <br /> BUSINESS NAME frnatrrr N,um) FACILITY IDg <br /> COUNTY _ <br /> STREET ADDRESS S )-( ZIP a 4 u 1 oG u 1 <br /> CITY 95 Z-0(I <br /> S+�R"}�N PHONE <br /> FMAIL ADDRESS ( Zof,)4573 -.k-7 9 3 <br /> 'S :11 ; il Yee <br /> U.NAME AND ADDRESS O-V — VER/OFERATORSUBMITTING R& Um <br /> (p�� ❑1.OWNER �a:1rOfH 1 R1 <br /> NAME UG +� acct�`�C V Q�f'altC{ C)'I OPERATOR <br /> l PHONE <br /> TITLE OF APPLICANT tI <br /> Oc 1/K4 <br /> MAILING ADDRESS ❑(MAIAVO ADDRESS SAME FACILITY ADDRESS) <br /> $' bq FI ,, STATE ZIP CODEFS L:O�, <br /> CITY 94,p CSC- `d Lit <br /> EMAIL ADDRESS ) r o e'— <br /> �l� . efi4Sb1.. �" U <br /> Please check reasons)why you believe that the California State Water Resources Control Board(State Water Board)notification is ba <br /> error.If you are requesting reconsideration for reasons#k 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 reconsideration is subject to verification. <br /> 1 ❑UST system(s)is Permanently closed.(DOCUMENTATION IS REQUIRED.) <br /> 2. ❑UST systern(s)is exempt from regulation,according to Section 25281(xxl)(A)-(D)of the Health and Safety Code, <br /> or Section 2621 of Title 23 of the Califamia Code of Regulations.For example,certain farm tanks and heating oil tanks we <br /> exempt(DOCUMENTATION IS REQUIRED.) <br /> 3. 'Closest component of UST systems)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 drinking 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 incorrectly located in Geotracker database. . <br /> ❑Public drinking water well(s)incorrectly located in Geotracker database. <br /> 4. 0 Other(explain): <br /> NOTE:SUBMITTAL INSTRUCTIONS ON RFNrERSE SIDE OF THIS FORM <br /> AI.APPLICANT SIGNATURE <br /> c"tiaution-I cortify that the information provided herein is true sad 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,puatshablPHONE by rim up l0 55000. <br /> eam <br /> NAME OF APPLICANT(print) (Z-I)q T'-9 7q3 <br /> !vl/ke C1 t"v <br /> DATE <br /> SIGNATURE OF APPLICANT <br /> FOR SWRCB USE ONLY <br /> WATT'NOTIFICATION MAILED nATF REQUEST RBCEIVD <br /> - <br /> OATFNb'OFtr'ATIONR.FC[F.VE.R gFf'F,f,IYFD BV <br />