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LIT TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY V (pnl0�i <br /> (one page per site) a® _of <br /> TYPE OF ACTION El 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 19 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6 TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same as FACILTY NAME or DBA-Doing Business As) 3 FACILITY:1 <br /> Tesoro#67077 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 'g LDoKI{ a <br /> C � q$ ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSI E S 1.GAS STATI N 3.FARM Li 5. GUMMERCIA ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency.name of supervisor of division.section or office <br /> REMAINING AT SITE trusbands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME A07 PHONE 408 <br /> Tesoro Refining and Marketing Co. 253-896-8700 <br /> MAILING OR STREET ADDRESS 409 <br /> 3450 S. 344th Way Suite 100 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Auburn WA 98001-5931 <br /> PROPERTY OWNER TYPE 01.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7. FEDERAL 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Tesoro Refining and Marketing Co. 253-896-8700 <br /> MAILING OR STREET ADDRESS 416 <br /> 3450 S. 3441h WaySuite 100 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Auburn WA 98001-5931 <br /> TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420 <br /> ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- 2 4 6 6 0 Call (916) 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ® 1. SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑ 3. INSURANCE ❑ 6. EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is Checked ❑ 1. FACILITY ❑2 PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification- certi that the informatio provided herein is true and accurate to the best of my knowledge. <br /> SIGNATAPPhjI;ANT DATE �� 424 PHONE 425 <br /> CS v/, 253-896-8801 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Robert E. Hoover Retail Environmental Administrator <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> �c 22ao ,tt_ .u- Co q&98 7 <br /> UPCF(1/99 revised) Formerly SW RCB Form A <br />