COMPLIANCE INFO 2006 - 2011 - Laserfiche WebLink

Home Browse Search

Request for Rec:,nsideration (RFR) Form RFR NO. For SWRCB use only. I. FACILITY/SITE INFORMATION BUSINESS NAME(FACILITY NAME) V,3 St=N Z e PAA k5 " FACILITY ID#= O O 0 111 KT9 MIkIiQ STIL t T i� ,W XM Q M STREL I,ADDRESS , 1 13 1J`h s,' ��I� � � � COUNTY S" Joa Q v►.s CITY M kw T F C�P� � C � ZIP CA Is EMAIL ADDRESS PHONE .� 0-0q) Q6'L5 (a 7154 II.NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING REQUEST NAMEVs t L-VC EQ S �m N ❑ t.OWNER [13.BOTH 1&2 �i 'G t g2.OPE24TOR TITLE OF APPLICANT M V-1 9 G PHONE I i, L,.S -I✓ { C• MAILING ADDRESS ((MAILING ADDRESS SAME AS FACILITY ADDRESS) CITY AN� STATE ZtP CODE 1 "t C44STATE 5 3 3 EMAIL ADDRESS Please check reason(s)why you believe that the California State Water Resources Control Board(State Water Board)notification is in error.If you are requesting reconsideration for reasons#1 through#3, documentation is required. If you do not include required documentation,your request for reconsideration application will be considered incomplete and will be returned.Include all supporting documentation you wish the State Water Board to consider when reviewing your request.All information submitted with requests for reconsideration is subject to verification. 1. ❑UST system(s)is permanently closed. (DOCUMENTATION 1S REQUIRED.) 2. ❑UST system(s)is exempt from regulation,according to Section 2528l(x)(1)(A)-(D)of the Health and Safety Code, or Section 2621 of Title 23 of the California Code of Regulations. For example, certain farm tanks and heating oil tanks are exempt. (DOCUMENTATION IS REQUIRED.) 3. ❑ Closest component of UST system(s)is greater than 1,000 feet from well head of any public drinking water well. Check applicable reason(s): If the request for reconsideration is based on evidence that the UST system in question is greater than 1,000 feet from a public drinking water well, include a demonstration that the well head is more than 1,000 feet from the closest component of the UST system.(DOCUMENTATION IS REQUIRED.) ❑BUST facility incorrectly located in Geotracker database. . ❑ Public drinking water well(s)incorrectly located in Geotracker database. 4. Other(explain): W Ej-L- M `3 LJ O 11 i q — 00 i L AMM 39 O t I t ct) L-0 C—?N T 1=D S1 U CH E R C-1- `i A S it L I F I F-Q AT THI. CI Ty o f wt A-r)1 E L Sh+J J[aR0.JtrJ t:_au�rt� t�l'FiC.CS CNvj J�PI.>,( >�t_1~ 'Tv TM►S Sl"C� l NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF THIS FORM Ill.APPLICANT SIGNATURE Certification—I certify,that the information provided herein is true and accurate to the best of my knowledge.Knowingly submitting a request 1'or reconsideration based on false or misleading information may be considered a violation of Health and Safety Code,Section 25299,punishable by fine up to$5000. 1st NAME OF APPLICANT(print) 7 (510)PHONE•4b�,5 '� 6 1 06� �l" �f� ,2>1�Q C V,U L 01EP S K Rr roI i� SIGNATURE OF APPLICANT (}'� DATE FOR SWRCB L7SF,ONLY DATE:NOTIFICATION MAILED DA FE REOUES'I RECEIVED :h't)"fINICAI'InNRI IE%—F_D REt_ER'E..DEKY