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Request for Reconsideration (RFR) FormRFR <br />NO. — <br />Fon' SWRCB use only. <br />I. FACILITY 1 SITE INFORMATION <br />BUSINESS NAME(pAcn.rrYNAMF) <br />PACILI'TY Ill# <br />STREHT ADDRESS+^-------- <br />COUNTY <br />CITY <br />!II' <br />EMAIL ADDRESS <br />PHONE <br />( ) <br />II. NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING <br />REQUEST <br />NAME, <br />❑ 1. OWNER ❑ 3. BOTH I d 2 <br />❑ ? OPERATOR <br />a,TITL E OF APPLICANT PHONE <br />MAILING ADDRESS ❑ (MAIIANU ADDRESS SAME AS FACILITY ADDRESS) <br />CPPV STA I L %IP COl)I <br />EMAIL ADDRESS <br />Please check reasons) why you believe that the California State Water Resources Control 13o nd (State Water lloard) notification is in <br />error. If you are requesting reconsideration for reasons #1 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 />ith requests for reconsideration is subject to verification. <br />UST system(s) is permanently closed. (DO('UMENTATION IS REQUIRED.) <br />2. El UST system(s) is exempt from regulation, according to Section 25281(x){ 1)(A)-(D) of the Health wid Safety Code, <br />or Section 2621 of"l'itle 23 of the Ca]ifornia ('odc of Regulations. Por examhlr, certain I'llnl tanl<s and heating oil tanks are <br />exempt. (DOCUMENTATION IS REQUIRED.) <br />Closcst component of UST system(s) is greater than 1,000 Peet from well head of any public di inking water well. Check <br />applicahk 1eason(s): II the- request Vol 1econsideratitnl is based oil evidencc that the UST system ill question is .greater than <br />1,000 feel hom ti putllc drinkllis' water we,]), mCande it denionsliatlon that the WCH head is 1110re than 1,000 IRCt _ <br />front the closest component of Clic LIST system. (DOCUMENTATION IS I211,QII lltf(,Dj <br />Us"l' facility incwlectly located in Gcotracker database. <br />Public driukinu, water well(s) incorrectly located in Geolinker database. <br />Other(explain)._ <br />NOTE: SUBMITTAL INSTRUCTION'S ON R 4WEIZSI? SIDE 01� TIIIS FORM <br />III. APPLICANT SIGNATI:JIZE <br />C'ertitication -- I certify' that the information provided herein is U'uc and accurate to the best of np knowledge. Knoicingly submitting a request for reconsideration <br />I)ased on false or misleading information map be considered a violation of llealth and safety Code, Section 25299, punishable by tine up to $-5000. <br />AME APPI.ICANT(pimt) PHONn <br />( ) <br />16NATURI'.0I APPLICANT- -- ---- - -- --- — <br />DATI � ---- <br />FOR S%XWj1 I'SV O,NI.Y <br />DA 11: NI )TI}_It' 113(". \I \n 1 D <br />1)y 11 10:Q_1,1 S I kI_t'I,�IVH) <br />IIA I I' ht'aru l( `-.I ON Rl CIFVI 1) <br />l(FC, JV1 1) 13) — <br />