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IED PROGRAM CONSOLIDATED FORW tv AL <br /> UNDERGROUND STORAGE TANK 04 q//p/p� _1u'Vfq <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <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 PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 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.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR X 6.OTHER Trust lands? ❑Yes X No <br /> II. PROERVY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> Union Pacific Railroad 402 271-2322 <br /> MAILING ADDRESS 409. <br /> J 1416 Dodge Street <br /> CITY 410 STATE all. ZIP CODE 412. <br /> Omaha NE 68179 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428.2 <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS 428-3 <br /> 2400 N. Glenville Drive <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> Richardson TX 75082 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS 416. <br /> 2400 N. Glenville Drive <br /> CITY 417. STATE 418 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 /> UALIZATION'UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 10 10 19 16 1 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> 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 /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATUREDATE ata. PHONE 425. <br /> �;- 9/3/09 (972) 729-5671 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Todd Harris Regional Environmental Manager <br /> UPCF UST-A Rev.(12/2007) <br />