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41 (,*- 1j`U2- NKS <br /> UNDERGROUND STORAGE TANKS - FACILITY vim <br /> (one page per site) Page of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK F FE D �J <br /> ❑6.TEMPORARY SITE CLOSURE 400(\, // <br /> I. FACILITY/SITE INFORM! AT,ION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILII`Y I <br /> Tesoro#67079 q01 W. 2 t-tj " <br /> 1 <br /> NEAREST CROSS STREET p.ocQ;,(U C�,r,Z�{D 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT* <br /> ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.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 trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes ® No 405 406 <br /> L PROPERTY OWNER INFORMATION' <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tesoro Refining and Marketing Co. 253-896-8700 <br /> MAILING OR STREET ADDRESS 409 <br /> 3450S. 344 th Way Suite 100 <br /> CITY 410 FSTATE 411 ZIP CODE 412 <br /> Auburn I WA 98001-5931 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> NER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Tesoro Refining and Marketing Co. 253-896-8700 <br /> MAILING OR STREET ADDRESS 416 <br /> 3450S. 344 th Way Suite 100 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Auburn WA 98001-5931 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> \ SIV.BOARD'OF E( UALIATIC?I .IrIs "STtRAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- 1 14 16 1 6 10 1 Call (916)322-9669 ifquestions arise 421 <br /> k Y R ! I#NCIAL REB Y Al <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.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 /> a" VL LEGAL._NQTI ATION�ANa"MAILING ADQR SS <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-I certifypt the information prov' ed herein is true and accurate to the best of my knowledge. <br /> SIGNAT O PP IC DATE 424 PHONE 425 <br /> "O� 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 /> UPCF(1/99 revised) Formerly SWRCB Form A <br />