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Request for Recesideration (RFR) Form RUR NO. <br />For SWRCB use only. <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (FACILITY ?JAMS) FACILITY IDS <br />STREET ADDRESS ICOUNTY <br />CITY ZIP <br />EMAIL ADDRESS PHONE <br />( ) <br />II. NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST <br />NAME <br />1. OWNER [13. BOTH I & 2 <br />El 2. OPERATOR <br />TITLE OF APPLICANT PHONE <br />MAILING ADDRESS El (MAILING ADDRESS SAME AS FACILITY ADDRESS) <br />CITY STATE ZIP CODE <br />EMAIL ADDRESS <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 #I 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 returned. Include all <br />supporting documentation you wish the State Water Board to consider when reviewing your request. All information submitted <br />with requests for reconsideration is subject to verification. <br />1. ❑ UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED.) <br />2. ❑ UST system(s) is exempt from regulation, according to Section 2528 1 (x)(1)(A)-(D) of the Health and Safety Code, <br />or Section 2621 of Title 23 of the California Code of Regulations. For example, certain farm tanks and heating oil tanks are <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 />El Public drinking water well(s) incorrectly located in Geotracker database. <br />4. ❑ Other(explain): <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br />III. APPLICANT SIGNATURE <br />Certification — 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 maybe considered a violation of Health and Safety Code, Section 25299, punishable by tine up to $5000. <br />NAME OF APPLICANT (print) PHONE <br />{ ) <br />SIGNATURE OF APPLICANT DATE <br />FOR SWRCB USE ONLY <br />MAILED <br />DATE REQUEST RECEIVED <br />EQATE,TIFICATION <br />)`I'IFIt'ATIhN HFCIE <br />RECEIVED BY <br />