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SRN-08-198 THU 09:00 J" TESORO TEL NO:209-464-7066 #629 P09 — <br /> FACII.ITYRIS7 EPA M NUMBER <br /> , <br /> G. FAC=Y OWNER OR OPERATOR INFORMATION: <br /> is the signer of this ccr irtcation the: ❑ Owner or ❑ Operator? <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: _ ZIP CODE: <br /> TELEPHONE NUMBER: U <br /> H. FINANCIAL ASSURANCE FOR CLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: $ (please tee Instructions before entering any dollar m unq <br /> B. TYPE OF CLOSURE ASSURANCE MECHANISM: <br /> C. MECHANISM IDENTIFICATION NUMBER(S): q <br /> (if applicablc) <br /> D. FINANCIAL IN9TTi1J1-ION, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: <br /> C <br /> i <br /> + ADDRESS: <br /> I <br /> CITY: STATE: ZIP CODE: <br /> E. EFFECTIVE DATE OF CLOSURE ASSURANCE MECHANISM: <br /> F. ORIGINAL DOCUMENT(S) ATTACHED: <br /> ❑ Attach the original document(s) used to satisfy the closure financial assurance requirements. <br /> ❑ Attach the detailed closure cost estimate that resulted in the cost shown in Item A (see attached model.) <br /> DTSC 1232(8196) Fom,erly 8113(1196) PAGE.2 OF 3 <br />