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Request for Re( sideration (RFR) Form UR NO. For SWRCB use only. I. FACILITY/SITE INFORMATION BUSINESS NAME(FACILITY NAME) FACILITY ID# 1 1 17-7 1 1 1 1 1 STREET ADDRESS COUNTY CITY ZIP EMAIL ADDRESS PHONE ( ) H.NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST NAME ❑ (.OWNER ❑3.BOTH 1&2 ❑2.OPERATOR TITLE OF APPLICANT PHONE MAILING ADDRESS ❑(MAILING ADDRESS SAME AS FACILITY ADDRESS) CITY STATE ZIP CODE EMAIL ADDRESS Please check reason(s)why you believe that the California State Water Resources Control Board(State Water Board)notification is in error. If you are requesting reconsideration for reasons#1 through#3,documentation is required.If you do not include required documentation,your request for reconsideration application will be considered incomplete and will be returned.Include all supporting documentation you wish the State Water Board to consider when reviewing your request.All information submitted with requests for reconsideration is subject to verification. 1. ❑ UST system(s)is permanently closed. (DOCUMENTATION IS REQUIRED.) 2. ❑UST system(s)is exempt from regulation, according to Section 2528l(x)(1)(A)-(D)of the Health and Safety Code, or Section 2621 of Title 23 of the California Code of Regulations. For example,certain farm tanks and heating oil tanks are exempt. (DOCUMENTATION IS REQUIRED.) 3. ❑ Closest component of UST system(s)is greater than 1,000 feet from well head of any public drinking water well. Check applicable reason(s): If the request for reconsideration is based on evidence that the UST system in question is greater than 1,000 feet from a public drinking water well,include a demonstration that the well head is more than 1,000 feet from the closest component of the UST system. (DOCUMENTATION IS REQUIRED.) ❑ UST facility incorrectly located in Geotracker database. . ❑ Public drinking water well(s) incorrectly located in Geotracker database. 4. ❑ Other(explain): NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM III.APPLICANT SIGNATURE 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 misleading information may be considered a violation of Health and Safety Code,Section 25299,punishable by fine up to$5000. NAME OF APPLICANT(print) PHONE ( ) SIGNATURE OF APPLICANT DATE FOR SWRCB LISE ONLY DATE NOTIFICATION MAILED DATE REO JEST RECEIVED 1)A I'F.NO"f IrICATION RFCIFVF_D 1ZWF..IVF,D BY