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` o <br /> Request for Rec sideration (RFR) Form RFR NO. <br /> For SWRCB use only. <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS A E ncii_rry Mei , FACILITY ID# FJAI <br /> qTO <br /> 1 � 10151� 1 <br /> c�� � �n ln <br /> STREET ADDRESS 3505 N 1� D c I\lf- 0 NTY ' <br /> c� 99 n Joa 0 v n <br /> CITY O c I[� n 1 l.A ZIP q 6^ i1 5 <br /> EMAIL ADDRESS N/A PHONE ��/_� <br /> (acq) q4 11� <br /> II.NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br /> NAMEpp ❑ 1.OWNER [:13.BOTH I&2 <br /> Vbn C r t+`5 V2.OPERATOR <br /> TITLE OF APPLICANTFa c 1141 <br /> M a na �il� PHONEI /rJ � 5 Lp'^2. <br /> MAILING ADDI&ES o�(MAII,1�ADDRESS SAME AS FACILITY ADDRESS) <br /> CITY 5+oG,f_t'"1o n ` C'� STATE CA/� ZIP Cqo� <br /> EMAIL ADDRESS I U <br /> Vonnie.Crites@NuStarEnergy.co. <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 rJnclude all <br /> supporting documentation you wish the State Water Board to consider when reviewing your request.Altio, �mitted <br /> with requests for reconsideration is subject to verification. J �!�� <br /> -jJ4 2 L- <br /> 1. ❑UST system(s)is permanently closed.(DOCUMENTATION IS REQUIRED.) Flv��//, 4 260J <br /> 2. ❑UST system(s)is exempt from regulation, according to Section 25281(x)(1)(A)-(D)of the Health ar6!�Ai� I�, . <br /> l�cL^ f YE,I; _ <br /> or Section 2621 of Title 23 of the California Code of Regulations.For example,certain farm tanks and heating�b� A <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 ter ell(s)incorrectly located in Geotracker database. <br /> 4. 4 Other(explain): �1L0)e5C. 3C C a*AC-h CCC a 6C-U Mtn+3TuD n <br /> NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br /> III.APPLICANT SIGNATURE <br /> Certilication-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(O PLIC 1p n.-c PHONE <br /> T]E <br /> 1 l u J /Y7�/'1(ihv q�3- 51�w2 <br /> SIGNATUI * F nPPLICnN"I- DATE 0i 23 � <br /> FOR SWRCB USE ONLY �J <br /> DATE NOTIFICATION NIAILED DATE REQUEST REC FIV ED <br /> 17n'T'k Nq�'Tl'1CATIQN-11IIIK FU RFCEIyj-lBY <br />