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Request for <br />BUSINESS NAME (FApLrrf NAMB) <br />_tsf deration (RFR) Form <br />r. -vArn rry i SITE fNF'ORN <br />FACH.UFY iD# <br />�L. —� i� � 1�YcEK - C� i�1 ty+s"► 4. ru'-..ter-+• <br />EL NAM' ADDRESS OF OwIlmR/OPERATOR <br />NAME l/!� <br />r�R't' L*(NN �3 <br />TITLE OF APPLICANT <br />6%KC3-1,P blRl=t C7� ns F� 1TY 4nnR <br />MAiL[NG ADDRESS l7 (MA>i ADDRESS SAI <br />crrY <br />My <br />EMAIL ADDRESS �[al�►S � �� ��� <br />tAm,2,r —L • — <br />"R NO. <br />rW SwRM,W only. <br />ZIP <br />PHONE <br />t�i5) t7• ,ZZ9 <br />TffNG.jEtEQ <br />1.OWNM Q3-BOTH1�2 <br />f7 2 oPERAT©R <br />PRONE <br />rG,[Si 8�Q10-G.77 9 <br />SPATE 21P CODE <br />Please check reason(s) why you believe that the Califor State Water R umen s <br />Control Board (State Nater Board) natlfiratloII 15 ut <br />for reasons #1 thron�h , � � ' � you do not indmle required <br />error_ If you are requesting recansl Mm wM be considered meomplefe and will be retar ued. Lndude an <br />documentation, your request for �ousideration aPi Water Board to consider when reviewing Your r tet. All information submitted <br />supporting documentation you wish the State <br />with requests for reconsideration is subject to verification. <br />1. ❑ UST systerr(s) is ply closed. WMMENTATION IS RzQDIRED ) <br />to Seciiam 2528I(xXIXA}(D) of do Health and Safety Code, <br />2, <br />UST <br />systems) is exempt firomxegulatiM aecoxdntg le, Certain Palm tanks and heating oil tanks are <br />or Section 2621 of Title 23 of the CaWomio Code of Regulations. For examp <br />exe t (DOCUMENTATION IS REQUIRED) water well. Cbeck <br />3. Closest component of UST systeud(s) is �� than 1,o00 feet from well Bead of any public drinking <br />applicable reason(s): If the retest <br />for reconsideration Is based on evidence that tate UST system m question is geater drem <br />1,000 feet from a public drinking water well, iuchlde a demonstration tbd the well head is more than 1,000 feel <br />from the <br />closest component of the UST systeol. (DOCUMENTATION IS REQUIRED-) <br />© UST facility incorrectly located in Geotxacker database. <br />[� Public drmkmg water wells) incorrectly located im Geotmcker database. <br />4. ❑ Other(explaiu): <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF TMS FORM <br />III, CANT SIGNATURE <br />subzMn a request for reconsideration <br />Certification — I certify fiat the luforntatioss provided keivis is true aad acctttsnke the batof my �orrled�e lone n to i500Q- <br />an be considered a violation or Hesidh and Safety Code, Section 2s M, Pned�ble by F <br />based on false or mismeadin& in% I PHONE <br />NAME OF APPLICANT (print) t(vl5) . O • 4nZZ•9 <br />MART ILj(#4t^I Cu114 <br />DATE L <br />SINATI)RE OF APPLICANT <br />G <br />1)A'r'F xnxTFICATION . <br />AATTSNOi[Ft AT N lePf Ixrt)FDB1C <br />