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JAN-08—'98 THU 09:00 ID:TESORO TEL NO:209-4�7UM6J--7066 4629 P09 <br /> 'FACIIdTY/1 U NAME _ EPA ED 1BER <br /> G. FACn1TY OWNER OR OPERATOR INFORMATION: <br /> Is the signer of this certification the: 0 Owner or ❑ Operator? <br /> NAME: <br /> ADDRESS: <br /> CITY: STATE: ZIP CODE: <br /> TELEPHONE NUMBER: �) <br /> D. FINANCIAL ASSURANCE FOR CLOSURE: <br /> A. ESTIMATED CLOSURE COSTS: $ (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 /> i <br /> D. FINANCIAL INSTITUTION, INSURANCE OR SURETY COMPANY, OR OTHER ORGANIZATION: <br /> NAME: <br /> i <br /> + ADDRESS: <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 /> DTSC 123](8196) Fom tdy 8113(1196) PAGE 2 OF 3 <br />