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. , y any x <br /> U&t dor econsi eratio <br /> t <br /> I '#F'AiCII;ITY <br /> w .�. <br /> : 1 TIONS x <br /> EISINESS NAME(FACLUTY RAt k }" ACILiTS <br /> STREET, <br /> TREET ADDRE S PHONE <br /> CITY COUNTY ZIP CODE <br /> II.NAME AND ADDRESS OF oWNEIJ6PII2ATo SUB NG,REQUEST <br /> NAME / a <br /> OWNER <br /> '` ❑2.01`ERATOR <br /> TITLE OF APPLICANT; € r PHONE <br /> 4W C_ It, 6 AAM k4 <br /> MAILING/ADDRESS / ❑04AIIdNG ADDRESS SAME AS FAcu rrY ADDRESS) <br /> CITYSTATE` ZIP CODE <br /> Please'check reason(s)why you believe thatthe California State Water Resources Control Board(SWRCB)'notification is irierror. If <br /> the request"for reconsideration is based on evidence that the UST-system in question is greater than.1,000 feet from a public drinking <br /> water well,include a demonstration that the center of the well head is more than 1,000 feet from the closest component of the UST <br /> system. If the request is based on`evidence that the UST system does not have a single-walled component, include supporting <br /> documentation. INCLUDE ALLSUPPORTING DOCUMENTATION YOU WISH THE SWRCB TO CONSIDER WHEN <br /> REVIEWING YOUR REQUEST.REQUESTS FOR RECONSIDERATION ARE SUBJECT TO VERIFICATION. <br /> 1. O I am not the owner or operator of a UST system.Check applicable reason: <br /> O Change of owner or operator." <br /> O No UST system(s)present. <br /> 2. O UST system is permanently closed. <br /> 3. `( )UST system is exempt from regulation,"according to Section 252$1(x)(1)(A)-(D)ofthe'Health and Safety Code,or Section <br /> 2621 of Title 23 of the California Code of Regulations.For example,certain farm tanks and heating oil tanks are exempt. <br /> -4. (PI No single-walled component in UST system(s). <br /> 5. ( )Closest component of UST system is greater than 1,000 feet from well head of any public drinking water well.Check <br /> applicable reason(s): <br /> ( )UST facility incorrectly located in GeoTracker database <br /> ( )PublicDrinking Water Wells)incorrectly located in GeoTracker database <br /> 6. ( )Other(explain) r <br /> NOTE:SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br /> III.APPLICANT SIGNATURE <br /> Certdicahon—t certify that the information provided herein is true and accurate to'the best of my 1*awledge,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 fine up to S5000. <br /> NAME OF APPLICANT(print) /►.-; PHONE <br /> mleVile)� <br /> SIGNATUREOF APP ICANT DATE <br /> r <br /> Na <br /> jill <br />