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TANKS UNDERGROUND STORAGE TANKS - FACILITY �P_()r- ( (one page per site) Page_1_o _1 TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT Z 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK R VED ❑&TEMPORARY SITE CLOSURE � �r f�Y 400 I. FACILITY/SITE INFORMATION B USIN ESS NAM E(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# � k � 1 Tesoro#67080 avyy u) '.t" Am Z-o Q 9 NEAREST CROSS STREET 95 Sib 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT* Lower Sacramento Z 1.CORPORATION [15.COUNTY AGENCY* BUSINESS Z 1.GAS STATION [-13.FARM [15. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 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 REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) 3 404 ❑ Yes Z No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE aoa Tesoro Refining and Marketing Co. 253-896-8700 MAILING OR STREET ADDRESS 409 3450 S.3441h Way Suite 100 CITY 410 1 STATE 411 ZIP CODE 412 Auburn WA 98001-5931 PROPERTY OWNER TYPE Z 1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7. FEDERAL 413 III. TANK OWNER INFORMATION TANK OWNER NAME ala PHONE 415 Tesoro Refining and Marketing Co. 253-896-8700 MAILING OR STREET ADDRESS 416 3450S.344 1h Way Suite 100 CITY 417 STATE 418 ZIP CODE 419 Auburn WA 98001-5931 TANK OWNER TYPE Z 1.CORPORATION ❑2.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7. FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK) HQ 44- 1 2 14 1 6 6 0 Call (916) 322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE Z 1.SELF-INSURED [:14.SURETY BOND ❑7.STATE FUND ❑ 10. LOCAL GOVT MECHANISM METHOD(s) ❑2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑ 3. INSURANCE ❑6. EXEMPTION ❑9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER Z 3.TANK 423 OWNER VII.APPLICANT SIGNATURE Certification- ertif hat the information rovided herein is true and accurate to the best of my knowledge. SIGNAT APPLI T DATE / 424PHONE azs 253-896-8801 NA OF APPLICANT(print) 426 TITLE OF APPLICANT 427 Robert E. Hoover Retail Environmental Administrator STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF (1/99 revised) Formerly SWRCB Form A