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ACTION REQUEST FORM —tor State Regulatory Progrwm Office s, aft, & <br /> Program Office Staff <br /> TECHNICAL REVIEW i ACTION REQUEST to be completed by SR� --#AFF - <br /> � y NIAR '� 1n36 # <br /> DATE: SRP Sta Clyde est <br /> io <br /> Name of facility: EPA f: '.4CR'� �a <br /> (CORRECT #-VERY IMPORTANT) <br /> Requesting closure I <br /> Requesting withdrawal � A <br /> Requesting exemption 1 ,� <br /> I <br /> Revisions: Requesting deletion of unit(s) <br /> Requesting addition of it( <br /> Requesting written responsg ,'k..• <br /> Requesting refund/with re base <br /> ;a pR a <br /> Other: CI <br /> ACTION to betaken by PO STAFF: <br /> Dater eived: Initials: <br /> OK for Closure Date of Closure: 3 <br /> *REASON FOR CLOSURE: <br /> OK for Withdrawal Date of Withdrawal: <br /> '*REASON FOR WITHDRAWAL: <br /> OK for Exemption Date of Exemption: <br /> *REASON FOR EXEMPTION: <br /> Delete Tier(s) : <br /> Delete Unit(s) : <br /> *REASON FOR DELETION: <br /> Other: <br /> Revisd'd 9/8/95 WP:ACTREQ.MB <br />