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Request for Reconsideration Fox <br /> I. FACILITY 1 SITE INFORMATION <br /> BUSINESS E wcILC'Y NAME FACILITY ID# <br /> ._._ dS PI <br /> STREET ADDRESS <br /> CIT Y - - COUNTY ZIP CODE <br /> H. NAME AND ADDRESS OF OWNERIOPERATOR SUBMIT TNG REQUEST <br /> NAME ❑ I.OWNER <br /> _ �__�YV ,5�.._ Q _ a ❑2.OPERATOR <br /> TITLE OF APPLICANT PHONE _ <br /> ----- <br /> AILING ADDRESSf—(IIAILI'NG ADDRESS SAME AS FACILITY ADDRESS) <br /> CITY STATE ZIP CODE ��_ __._.___ <br /> Please check reason(s)why you believe that the California State Water Resources Control Board(SWRCB)notification is in error. If <br /> you are requesting reconsideration for reasons #2 through #4, documentation is required. IF YOU DO NOT INCLUDE <br /> REQUIRED DOCUMENTATION, YOUR REQUEST FOR RECONSIDERATION APPLICATION WILL BE <br /> CONSIDERED INCOMPLETE AND WILL BE RETURNED, INCLUDE ALL SUPPORTING DOCUMENTATION YOU <br /> WISH THE SWRCB TO CONSIDER WHEN REVIEWING YOUR REQUEST. REQUESTS FOR RECONSIDERATION <br /> ARK SUBJECT TO VERIFICATION. <br /> 1. 1y(vl I arty not the owner or operator of a UST system.Check applicable reason: <br /> (,Change of owner or operator. (Provide name and address of new owner/operator, if known) <br /> ( ) No UST system(s)present. <br /> 2 ( ) UST system(s)is permanently closed. (DOCUMENTATION IS REQUIRED) <br /> UST system(s) is exempt from regulation,according to Section 25281(x)(1)(A)-(D) of the Health and Safety Code, or <br /> Section 2621 of Title 23 of the California Cade of Regulations. For example, certain farm tanks and heating oil tanks are exempt. <br /> (DOCUMENTATION IS REQUIRED) <br /> 4. ( ) Closest component of UST system(s) is greater than 1,000 feet from wellhead 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 1,000 <br /> feet from a public drinking water well,include a demonstration that the well head is more than 1,000 feet from the closest <br /> component of the UST system. (DOCUMENTATION IS REQUIRED) <br /> { )UST facility incorrectly located in GeoTracker database <br /> ( )PablicDrinking Water Well(s)incorrectly located in GeoTracker database <br /> 5. Other(explain) <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 submitting a request for reconsideration based on raise or <br /> misleading information may be considered a violation of Health and Safety Code,Section 25299, punishable by rine up to$5000. <br /> NAME OF APPLICANT(print) __ PHONE — <br /> { ) <br /> SIGNATURE OF APPLICANT — DATE <br /> FOR.AGENCY.USE ONLY <br /> DATE NOTIFICATION MAILED DATE REQUEST RECEIVED DATE DECISION DUE DATE OF DECISION NOTIFICATION <br /> DATE NOTIFICATION RECIEVED RECEIVED BY DATE OF DIVISION DECISION ItEQCII.SF APPROVED <br /> REQUEST-DENIED, <br />