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UWJED PROGRAM CONSOLIDATED FORN,. <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION(One form per facility) <br /> � - 400. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 0 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check cm hem only) X 3.RENEWAL PERMIT 0 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> WN W <br /> IN <br /> 6 <br /> TOTAL NUMBER OF USTS AT FACILITY 404 FACILITY ID# F A 0 0 0 <br /> (Agency use onb') IN 31814161 1 1 <br /> BUS ES-SN-"E(S..FACn NAr.ffi.DM-DoingB-inMM) <br /> MCI, doing business as, Verizon Business <br /> BUSINESS SITE ADDRESS 1m. CITY <br /> 2500 W. Turner Road Lodi <br /> FACILITY TYPE 0 L MOTOR VEHICLE FUELING [1 2.FUEL DISTRIBUTION 03. Is the facility located on Indian Reservation or <br /> ❑ 3.FARM 0 4.PROCESSOR X 6.OTHER Trust lands? 0 Yes XNo <br /> wu <br /> N <br /> PROPERTY OWNER NAME 401 PHONE <br /> 40B- <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS <br /> 2400 N. Glenville Drive <br /> CITY 410. STATE 411. ZIP CODE 41Z <br /> Richardson TX 75082 <br /> WIRP <br /> T.0 INFORM?�W(OW"W <br /> TANKOPERATORNAW 4�1 PHONE <br /> MCI, doing business as, Verizon Business (972)729-5671 <br /> MAILING ADDRESS 428-3 <br /> 2400 N. Glenville Drive <br /> CITY 4a STATE 4'8-5 ZIP CODE 4� <br /> Richardson TX 75082 <br /> IN <br /> I REV& 'M <br /> A, <br /> TANK OWNER NAME 414. PHONE 415. <br /> MCI, doing business as, Verizon Business (972)729-5671 <br /> MAILING ADDRESS 41& <br /> 2400 N. Glenville Drive <br /> CITY 417. STATE 418. Z[pC0DE 419. <br /> Richardson TX 7 082 <br /> OWNER ME: 0 4.LOCAL AGENCYIDISTRICT 0 5.COUNTY AGENCY 0 6.STATE AGENCY 420. <br /> 0 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> TY(TK)HQ 44- 0 0 10 19 6 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421, <br /> 6amA <br /> 75,00,14 HIS- to* -k <br /> Issue permit and send legal notifications and mailings to: 0 1.FACILITY OWNER X 4.TANK OPERATOR 423 <br /> [1 3.TANK OWNER 0 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 4 <br /> 2g <br /> -71 4 <br /> CERTIFICATION: I cerci that the information provided herein is true,accurate,and in full compliance with legal require ents. <br /> APPLICANT SIGNATURE DATE 4N 1 PHONE <br /> 15/3/10 (972) 729-5671 -4r <br /> APPLICANT NAME(print) 426. 1 APPLICANT TITLE <br /> Todd Harris Regional Environmental Manager <br /> UPCF UST-A Rev.(172007) <br />