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Quest for Reconsideration Fo <br />I. rACMITY !SITE EWORMA.TION . <br />eUSMESS NAb/1�E lrnea,�rr vAyer<< ��qq��//,,.�, FACILITY IDK <br />-- <br />STRYET ADOR�j' ,.- PHONE- <br />.-----_.,t-",.75� <br />CITY COUNTY ZIP CODE <br />9!91WONMENT <br />11. NAME AND ADDRESS OF OWNEWOPERATOR SUBI HrmG REQUEI/SERVIcpq <br />NAME tJ / 33.OwNER <br />P4 YYl a. <br />TITLE OFAPPLICANT _ PHONE <br />�1A ILING AD�RES$�i ❑f�rAdING ADDA£SS SLAM1fE .yC FACII.TfY ACORaa41 <br />CrrY TATE ZIP COOS <br />Please check reawn(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 W. documentation is required. IF YOU DO NOT INCLUDE <br />REQUIRED DOCUMENTATION, .YOLR REQUEST FOR RECONSIDERATION APPLICATION WILL BE <br />CONSIDERED INCONtPLETE AAYD WILL BE RETURNED. LYCLUDE ALL SUPPORTING DOCUMENTATION YOU <br />WISH THE SWRCB TO CONSIDER WHEN REVIEWING YOUR REQUEST. REQUESTS FOR RECONSIDERATION <br />ARE SUBJECT TO VERIFICATION. <br />L (,) I am not the owner or operator of a UST system. Check applicable reason: <br />( ) Change of owner or operator. (Provide tame and address of new ownerroperata, if known) <br />( ) No UST systein(s) pmoeat. <br />2. (} UST systein(s) is perrunneatty closed. (DOCUMENTATION IS REQUIRED) <br />3. ( ) UST systern(s) is exempt from reguiatiory accerding to Section 23281(x) (1)(A)-(D) of the Health and Safety Code, or <br />Section 2821 of Title 23 of the California Code ofHegulations. For example, certain farm tanks and heating oil tanks are exempt <br />(DOCUMENTAT16N IS REQUIRED) <br />4{ 'Closest component of UST system(s) is greater than LOW feet tiom well head of any public drinking water well. Check <br />/'W-ltcahlr resion(s): If the request for reconsideration is based on evidence thatthe UST system in question is grcatcr awn 1,000 <br />feet from a public drinking water well, include a demonstration that the well head is mora !batt 1,000 feer from the closest <br />component of the UST system. (DOCVIKENTATION IS REQGIREA) <br />�UStT facility incorrectly located in GeoTtacker database <br />blicDrinlong.Watc Well(s) incorrectly located in GeoTrackerdatabase <br />f. ( ) other (explain) lil> ii S4riY, - %r $ b*VLAAM <br />V Ot i✓ <br />>iwre37 LiC �1LOT C, rP let <br />MiTT <br />SGB iSTRt IONS REVE <br />: a- SIDE OP s W J <br />III, APPLICANT SIGNATURE <br />ceranueoo - t'e ry me Wermsdw provided Semin b trw end *carte%" aM Mat erne t.e..kd K". <br />� �ea E<• n reQnal Porn mWeretmn Fa,ta on rake or <br />mWeodkq lnJb(maeeen nmtlrrcd arlKYsee sr eeNeb orad Srkq�Cade. aseeen tff9r, pMkNnk 6r aria op to 550Je. <br />up M on. <br />NAME 099 CANT ip�..— ._....__.._._ .._ _... <br />PHONF. <br />SCG;*TU RF OP DATE <br />+AGiCX USE MY, ar <br />GATE NaTL'tCA170N MIt1LED <br />�RfAXE pp :r <br />DATcD roN OSIF .' :., ,OF+pEC131UN Y071EtCATION <br />•: _. <br />. <br />b4TP ND'rlr(CAnU4 RE <br />c. - Ct6VED� <br />` " v C.SiT a <br />DATE OFDIY,6IOND�1dN y�. y ,BEi2t7E+4T�tPPItOVFP, <br />OEEIiPTA <br />i/ yD <br />,fir <br />