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Request for Re( sideration (RFR) Form UR NO. <br /> `1 For SWRCB use only. <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(FACUTY NAME) FACILITY ID# <br /> STREET ADDRESS COUNTY <br /> CITY ZIP <br /> EMAIL ADDRESS PHONE <br /> ( ) <br /> H.NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br /> NAME ❑ 1.OWNER ❑3.BOTH 1&2 <br /> ❑2.OPERATOR <br /> TITLE OF APPLICANT PHONE <br /> MAILING ADDRESS ❑(MAILING ADDRESS SAME AS FACILITY ADDRESS) <br /> CITY 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 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 systems)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 /> 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 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. ❑ 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 <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 /> NAME OF APPLICANT(print) PHONE <br /> ( ) <br /> SIGNATURE OF APPLICANT DATE <br /> FOR SWRCB USE ONLY <br /> DATE NOTIFICATION MAILED DATE REQUEST RECEIVED <br /> I)AI'F._NOTNICA'I'ION RI C1F'VEI:) RECEIVEILBY <br />