Application for Change/Transfer Decision to Withdraw a Record of Decision and Report of Exam

Date:

To:Department of Ecology

From:Water Conservancy Board Name:

Re:Withdrawal of Record of Decision and Report of Examination

A meeting of the (Board Name) Water Conservancy Board was conducted in compliance with Chapter 42.30 RCW at (location of meeting) on(date) .

The board had previously issued a Record of Decision and Report of Examination on (date of decision) in the matter of Application for Change/Transfer No. (application number) filed by(applicant name) . At the meeting mentioned above and by a majority vote, the board withdrew the referenced issued Record of Decision and Report of Examination for the following reason(s):

The withdrawal of the referenced Record of Decision and Report of Examination is effective as of the adjournment of the meeting of the board during which it was adopted. Upon Ecology concurrence to this withdrawal, the Ecology review period provided by RCW 90.80.080 is terminated without prejudice for the referenced application for change/transfer.

The applicant (did or did not) participate in the meeting and (concurs or does not concur) with the withdrawal of the board’s previous decision.

The board adopts the following plan for action on the application (check one):

The board intends to revise and resubmit for Ecology review the record of decision and report of examination for the subject application.

The board will take no further action on the subject application and has informed the applicant that the application may be filed with Ecology for processing.

Information relevant to the board’s withdrawal action and a record of the Board’s vote in this matter are attached.

Water Resources Program

Application for Change/Transfer

Decision to Withdraw a Record of

Decision and Report of Examination

WATER CONSERVANCY BOARD NAME:

Applicant Name:

Application Number:

The (Board name) Water Conservancy Board hereby withdraws the Record of Decision and the Report of Examination for the entitled water right transfer issued on (date Record of Decision was signed) in accordance with the accompanying resolution of the board and submits this resolution to the Department of Ecology.

It is understood that with the concurrence of Ecology to this withdrawal, that the decision review period provided by RCW 90.80.080 for Ecology review of the previous decision of the board is terminated without prejudice. No board decision regarding the titled application for change/transfer is before Ecology for review.

Water Conservancy Board Name: / Date:
Chair Name: / Signature:
(choose one)
Approve Deny Abstain Recuse
Other (please explain)
Water Conservancy Board Name: / Date:
Title:
Name: / Signature:
(choose one)
Approve Deny Abstain Recuse
Other (please explain)
Water Conservancy Board Name: / Date:
Title:
Name: / Signature:
(choose one)
Approve Deny Abstain Recuse
Other (please explain)
Water Conservancy Board Name: / Date:
Title:
Name: / Signature:
(choose one)
Approve Deny Abstain Recuse Other (please explain)
Water Conservancy Board Name: / Date:
Title:
Name: / Signature:
(choose one)
Approve Deny Abstain Recuse Other (please explain)

This document was mailed to the appropriate Regional Office and other interested parties via certified mail on this date:

Please check the appropriate Regional Office:

Northwest Regional Office
3190 – 160thAve SE
Bellevue, WA 98008
Eastern Regional Office
4601 N. Monroe St.
Spokane, WA 99205
Southwest Regional Office
PO Box 47775
Olympia, WA 98504
Central Regional Office
1250 W. Alder St.
Union Gap, WA 98903

ECY 040-107 (Rev 05-2014)To request ADAaccommodationincluding materials in a format for the visually impaired, call Ecology Water Resources Program

at 360-407-6872.Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341.