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JAN-08-198 THU 09:00 ' ESORO TEL NO:209-4' —'166 #629 P09 — <br /> low~ w <br /> r <br /> FACII ITYr1"IST NAS EPA M NUMBER <br /> G. FACILITY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the: L1 Owner or ❑ Operator? <br /> NAME: <br /> ADDRESS: <br /> I <br /> CTTy: STATE: _ ZIP CODE: <br /> TELEPHONE NUMBER: U <br /> II. FINANCIAL ASSURANCE FOR CLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: S (Please see instructions before entering any dollar amount) <br /> B. TYPE OF CLOSURE ASSURANCE MECHANISM: <br /> C. MECHANISM IDENTIFICATION NUMBER(S): N <br /> ! (if applicable) <br /> D. FINANCIAL INSTTI-UTION, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: <br /> I <br /> ADDRESS. <br /> i <br /> CITY: STATE: ZIP CODE: <br /> i <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 /> DISC 1232(8196) Formerly 8113(1196) PAGE 2 OF 3 <br />