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........................... <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION [1 1.NEW PERMIT El 5.CHANGE OF INFORMATION 0 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) <br /> X 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE rl 9.TRANSFER PERMrr <br /> TOTAL NUMBER OF USTs AT FACILITY 4"* FA'ILrrY ID I <br /> (A&cy Use Only) <br /> BUSINESS NAME(San*as FAciLrry NAME DBA-Doing Bi..A,) 3. <br /> MCI, doing business as, Verizon Business <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 13850 N. DeVries Road Lodi <br /> FACILITY TYPE [1 1.MOTOR VEHICLE FUELING C1 2.FUEL DISTRIBUTION 4°3. Is the facility located on Indian Reservation or 405. <br /> 0 3.FARM 0 4.PROCESSOR X 6.OTHERTrust lands? Yes XNo <br /> d <br /> PROPERTY OWNER NAW 407. PHONE 4M. <br /> Union Pacific Railroad 402) 271-2322 <br /> MAILING ADDRESS 409. <br /> 1416 Dodge Street <br /> CITY 410. STATE 411. Zip CODE 412. <br /> Omaha NE 68179 <br /> w <br /> TANK OPERATOR NAME 4294. PHONE 428-2 <br /> MCI, doing business as, Verizon Business (972)729-5671 <br /> MAILING ADDRESS 429.3 <br /> 2400 N. Glenville Drive <br /> CITY 42&4 STATE 429-5 ZIP CODE 42" <br /> Richardson TX 75082 <br /> TANK OWNER NAME 414. PHONE 415. <br /> MCI, doing business as, Verizon Business 1 (972)729-5671 <br /> MAILING ADDRESS 416. <br /> 2400 N. Glenville Drive <br /> Crry 417. STATE419. ZIP CODE 419. <br /> Richardson TX 75082 <br /> OWNER TYPE: 0 4.LOCAL AGENCY/DISTRICT El 5.COUNTY AGENCY 0 6.STATE AGENCY 420. <br /> 0 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> .................. <br /> 0"6 0717-0 0("E, <br /> -TV-(rK)HQ 44- 1 0 10 1 019 1 6 1 6 1 can the State Boardof Equalization,Fuel Tax Division,ff 421.there are questions. <br /> A. <br /> M ow . <br /> 3 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER X 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> CERTIFICATION: I certify that the information provided herein is trme,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE Gi rN DATE 424. 1 PHONE 425. <br /> 9/3/09 (972)729-5671 <br /> APPLICANT NAME(print) 4w. APPLICANT TITLE 427 <br /> Todd Harris Regional Environmental Manager <br /> UPCF UST-A Rev.(12/2007) <br />