Laserfiche WebLink
May 28 09 09: 12a <br /> _— p. 14 <br /> Request for Rec sideration (RFR) Form RFR NO. <br /> Q For SWRCH un only. <br /> L FACILITY I STU 111WORMATION <br /> M33NESS NAME Aatrrrwwq FAC11.1`1Y 1D# <br /> IF1 I CIO Y 5 5 <br /> I'- <br /> STKEh-f ADDRESS I <br /> y r in LQinary <br /> lIP <br /> `tAIL ADDP SS PHONE <br /> F <br /> II.NAM AND ADD SS OF OWNERIOP'ERATOR SUBMITITNG REQUM <br /> NA'W i]1.OWNER 3.BOTH I S<2 <br /> n FJ--JoL r S ❑2.OPERATOR <br /> T OF APP T PHONE <br /> Cn u i ron Pn rnr n,S�rc>+vr g 5 5- $ 15 <br /> MAILING ADDRESS O(1d LING AD6RFSS SAME AS FACILITY ADDRESS) <br /> 45� ,t4h {`F+kla-� 5�e 1 <br /> r n C-)- <br /> 11-ADDRESS <br /> Plcase 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#1 through t}3,docu=rrtation 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 dosed(DOCUMENTATION IS REQUIRED.) <br /> 2. ❑UST systcm(s)is exempt from regulation,according to Section 25281(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 fawn tanks and heating oil tanks are <br /> exempt.(DOCUINE07ATION IS REQUIRED.) <br /> 3. gClosest 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,cet from a public drin}dng water well,include a demonstration that the well head is more than 1,000 feet <br /> from the closest component of the UST system(DOCUIMENTATION IS REQUIRED.) <br /> ❑USI'facility incorrectly located in Geotracker database. <br /> ❑Public drinking water well(s)incorrectly located in Geotracker database. <br /> 4. ❑Othcr(explain): <br /> NOTE:SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM <br /> III.APPLICANT SIGNATURE <br /> Certiliution-I trstiry that the Information provided uerein is true and stearate to the beat of my knowledge.Knowingly submitting a retiam for reconsideration <br /> based on false or miskading in(brmation may be canaidered a violation of Ream and Safety Code,Sectlon 25299,punishable by tine up to$%GO. <br /> NAE OF APPLIC.A N (print) PHONE <br /> r i <br /> fi l�1 t (X <br /> tSl&1N,ATUMt,0F'A.?P�1U N-r DATFa4Q4A J4 SFORL_ D f]4 tti REQUEST RZ-CG1vtTIDAri N 1 CATION_i !!C V ItIL'HiyF1313Y <br />