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6� <br /> Ar,„n1 <br /> DIED PROGRAM CONSOLIDATED FORS <br /> UNDERGROUNDSTORAGETANK O <br /> OPERATING PERMIT APPLICATION-FACILITY INFO <br /> L tY) <br /> TYPE OF ACTION El1.NEW PERMIT El5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLosi) 400_ <br /> (Check one item only) X 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE El 9.TRANSFER PER�ruely 1. 0 'Mo <br /> I. FACILITY INFORMATIONp p�WAST HEALTH <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID N F A - 0 O O - B t F W SIJ t <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Sameu FACILITY NA or DBA-Doing Bust..An) 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 4a3. Is the facility located on Indian Reservation or 405, <br /> ❑ 3.FARM ❑ 4.PROCESSOR X 6.OTHER Trust lands? ❑Yes X No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407_ PHONE ao8_ <br /> MCI, doing business as, Verizon Business 972 729-5671 <br /> MAILING ADDRESS 409_ <br /> 2400 N. Glenville Drive <br /> CITY 410. STATE 411, ZIP CODE 412, <br /> Richardson TX 75082 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42&1. PHONE 423-2 <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS 428-3 <br /> 2400 N. Glenville Drive <br /> CITY 4284 STATE 423-5 ZIP CODE 425-6 <br /> Richardson TX 75082 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> MCI, doing business as, Verizon Business (972) 729-5671 <br /> MAILING ADDRESS 416. <br /> 2400 N. Glenville Drive <br /> CITY 410. 1 STATE 413. 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- 9 6161 Call the State Board of Equalization,Fuel Tax Division.if there are questions. 431_ <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 /> ao6. <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 SIGNATURE 1 DATE 424. 1 PHONE 425, <br /> 972 729-5671 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> Todd Harris Re Tonal Environmental Manager <br /> UPCF UST-A Rev.(12/2007) <br />