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V. <br /> IFIEDPROGRAM CONSOLID <br /> ATED <br /> ANK ,PEEVLIT/t <br /> UNDERGROUNDSTORAGE TANKOPERATING PERMIT APPLICATION -FACILITY INFORe � <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) X 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PE HEALTH <br /> I. FACILITY INFORMATION t PERMMSERVICES <br /> TOTAL NUMBER OF USTs AT FACILITY 4N FACILITY ID# 1 <br /> 1 (Agency U5e Only) F A 0 0 0 - 3 8 4 6 <br /> BUSINESS NAME(Same m FACn,r1Y NAME or DBA-Doing B.m.As) 3' <br /> MCI, doing business as, Verizon Business <br /> BUSINESS SITE ADDRESS 103, CITY 104- <br /> 2500 W. Turner Road Lodi <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM SSOR X 6.OTHER Trust lands? o Yes X No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME -Ir7 PHONE 408. <br /> MCI, doing business as, Verizon Business 972 729-5671 <br /> MAILING ADDRESS 409, <br /> 2400 N. Glenville Drive <br /> CITY 410 1 STATE 411. ZIP CODE 4¢, <br /> Richardson TX 75082 <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 028-1_ PHONE 428-3 <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS 428-3 <br /> 2400 N. Glenville Drive <br /> CITY 11'- S I A IF 428-5 ZIP CODE 4284 <br /> Richardson TX 75082 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME <br /> - 4L4. -PHONE 415 <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS - 416. <br /> 2400 N. Glenville Drive <br /> CITY 417, 1 STATE ala. ZIP CODE 419. <br /> Richardson TX 75082 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1010101916161 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421, <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER X 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> "'k,1 <br /> fm <br /> VII. APPLICANT SIGNATURE C= <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with le al requirements. C.: <br /> APPLICANT SIGNATURE DATE 420- PHONE ,'F 425. <br /> 4/22/11 972) 729-5671 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Todd Harris Regional Environmental Manager <br /> UPCF UST-A Rev.(12a007) completed <br />