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r-1 <br />An <br />Request for Reconsideration (RFR) Form <br />RM NO. <br />For S WRCB use only. <br />L FACILITY / SITE INFORMATION <br />BUSINE N ACILITYNAME) <br />FACILITY ID# <br />STREET ADDRESS // <br />COUNTY <br />CTTY <br />ZIP <br />96857 9 35- 74�, <br />EMAIL ADD SS <br />X+ o <br />PHONE <br />('Wo -p $ 33 - 94'/ <br />IL NAME AND ADDRESS OF OWNER/OPERATOR SUBMITTING <br />JREQUEST <br />NAME L <br />OWNER 3. BOTH I & 2 <br />2. OPERATOR <br />!r <br />TITLE OF APPLICANT <br />PHONE <br />e)— <br />MAILING ADDRESSING DRESS SAME FACILITY ADDRESS) <br />c t <br />#611S - rr�, ; 61LI <br />CITY <br />/� <br />STATE <br />ZIP CODE <br />EMAIL ADDRES."+"g O mmx <br />Please 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 #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 />with requests for reconsideration is subject to verification. <br />1. ❑ UST system(s) is permanently closed. (DOCUMENTATION IS REQUIRED.) <br />2. ❑ UST system(s) is exempt from regulation, according to Section 2528t(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 farm tanks and heating oil tanks are <br />exempt. (DOCUMENTATION IS REQUIRED.) <br />3. VClosest 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 feet from a public drinking water well, include a demonstration that the well head is more than 1,000 feet <br />fromIe closest component of the UST system. (DOCUMENTATION IS REQUIRED.) <br />UST facility incorrectly located in Geotracker database. <br />ZPublic drinking water well(s) incorrectly located in Geotrracker database. / <br />4. olther exp ): �� � <br />.-O I✓ Ib 1.± V /77/r- 1 A, <br />NOTE: SUBMITTAL INSTRUCTIONS ON REVERSE SIDE OF TffiS 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 <br />based on false or misleading information may be considered a violation of Health and Safety Code, Section 25299, punishable by fine up to $5000. <br />• <br />NAME OF (�� o� � <br />e f4.� <br />PHONE 3 �� P - <br />( ) 9 3 - T 'P— <br />SIGNATURE OF APPLIC <br />SIGNATURE <br />DATE <br />1_7_ /0 <br />FOR SWRCB USE ONLY <br />DATE NOTIFICATION MAILED <br />DATE REQUEST RECEIVED <br />DATE NOTIFICATION RECIEVED <br />I RECEIVED BY <br />