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0 <br />BUSINESS NAME (FACIUTYNAME) v FACILITY ID# <br />STREET ADDRESS Pr DANE <br />CITY COUNTY -Z-"-1 CODE 7 <br />/Y.�ch Cam,-�4'k7e Qrl 17,1c-p-V.I <br />II. NANIE AND ADDRESS OF OWNER/OPERATOR SUBN -G REQUEST <br />NAME ®.. OWN -ER <br />CeE ATOR <br />TITLE OF APPLICANT PFrONE <br />-30? <br />MAILING ADDRESS ❑ (MA—:NG/ .ADDRESS SAME AS FACILITY" ADDRESS) <br />�Ci• ��Jr r�L� <br />CITY � � � STATE Z? CODE <br />OG e gs-o2Q <br />Please check reason(s) why you believe that the California State Water Resources Control Bca d (SWRCB) notification is in error. If <br />you are requesting reconsideration for reasons #2 through #4, documentation is requred_ IF YOU DO NOT INCLUDE <br />REQUIRED DOCLIIENTATION, YOUR REQUEST FOR RECONSIDERATION APPLICATION WILL BE <br />CONSIDERED INCOMPLETE AND WILL BE RETURNED. INCLUDE ALL SL-PPORT1 G DOCUMENTATION YOU <br />WISH THE S`VRCB TO CONSIDER WHEN REVIEWING YOUR REQUEST. REQL-ESTS FOR RECONSIDERATION <br />ARE SUBJECT TO VERIFICATION. <br />1. ( ) I am not the owner or operator of a UST system. Check applicable reason: <br />( ) Chance of owner or operator. (Provide name and address of new owner/operato_. --' gown) <br />( ) No UST system(s) present. <br />2. ( ) UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED) <br />3. ( ) UST system(s) is exempt from regulation, according to Section 25281(x) (1)(A) -(D) o rhe Health and Safety Code, or <br />Section 2621 of Title 23 of the California Code of Regulations. For example, certain far-- -=nl- and heating oil tanks are exempt. <br />(DOCUMENTATION IS REQUIRED) <br />4. M Closest component of UST system(s) is greater than 1,000 feet from well head of an-.- drinking water well. Check <br />applicable reason(s): If the request for reconsideration is based on evidence that the UST s•s:em in question is greater than 1,000 <br />feet from a public drinking water well, include a demonstration that the well head is more 1,000 feet from the closest <br />component of the UST system (DOCUMENTATION IS REQUIRED) <br />MUST facility incorrectly located in GeoTracker database <br />( ) Public Drinking Water Well(s) incorrectly located in GeoTracker database <br />5. Other (explain) <br />5e, h4rll /rloeSte, GeJr <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br />M. APPLICANT SIGNATURE <br />Certification — I certify that the information provided herein is true and accurate to the best of my knowledge. Knowingly subcsimizzg 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 i <br />NAME OF APPLICANT (print) PEC` E <br />4tP -3079 <br />SIGNATURE OF APPLICAN_DA- u� �� <br />a <br />l r <br />FOR AGENCY USE ONLY <br />DATE NOTIFICATION MAILED DA E REQUEST RECEIVED DATE DECISION DUE DATE OF DECISION NOTIFICATION <br />BATE 1!IOTIFiCATION RELIEVED RECEIVED BY DATE OF DIVISION DECISION. REQt#FS IPPROVEF r <br />- 3T?DE1�IiEF3_ _ <br />