CM-2018-1686 - 4/13/2018TCEQ
TCEQ Core Data Form
TCEQ Use Only
For detailed instructions regarding completion of this form, please read the Core Data Form Instructions or call 512-239-5175.
SECTION I: General Information
1. Reason for Submission (If other is checked please describe in space provided.)
❑X New Permit, Registration or Authorization (Core Data Form should be submitted with the program application.)
❑ Renewal (Core Data Form should be submitted with the renewal form) I ❑ Other
2. Customer Reference Number if issued Follow this link to search 3. Regulated ntit Reference Number if issued
CN 600413181 for CN or RN numbers in RN
**
SECTION II: Customer Information Central Registry
4. General Customer Information
5. Effective Date for Customer Information Updates (mm/dd/yyyy)
❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership
❑Chan e in Legal Name Verifiable with the Texas Secretary of State or Texas Comptroller of Public Accounts
The Customer Name submitted here may be updated automatically based on what is current and active with the
Texas Secretary of State (SOS) or Texas Comptroller of Public Accounts (CPA).
6. Customer Legal Name (If an individual, print last name first: e.g.: Doe, John) If new Customer, enter previous Customer below
7. TX SOS/CPA Filing Number
8. TX State Tax ID (11 digits)
9. Federal Tax ID (s digits)
10. DUNS Number (if applicable)
11. Type of Customer:
❑ Corporation
❑ Individual
Partnership: ❑ General ❑ Limited
Government: ❑ City ❑ County ❑ Federal ❑ State❑Other
❑ Sole Proprietorship
❑Other:
12. Number of Employees
❑0-20 021-100 ❑101-250 0251-500 0501 and higher 1E:1
13. Independently Owned and Operated?
Yes ❑ No
14. Customer Role (Proposed or Actual) - as it relates to the Regulated Entity listed on this form. Please check one of the following:
❑Owner ❑ Operator ❑ Owner & Operator
❑Occupational Licensee ❑ Responsible Party ❑ Voluntary Cleanup Applicant ❑Other:
15. Mailing
Address:
City
State
ZIP
ZIP + 4
16. Country Mailing Information (if outside USA)
17. E -Mail Address (if applicable)
18. Telephone Number
19. Extension or Code
20. Fax Number (if applicable)
SECTION III: Regulated Entity Information
21. General Regulated Entity Information (If 'New Regulated Entity" is selected below this form should be accompanied by a permit application)
❑X New Regulated Entity ❑ Update to Regulated Entity Name ❑ Update to Regulated Entity Information
The Regulated Entity Name submitted may be updated in order to meet TCEQ Agency Data Standards (removal
of organizational endings such as Inc, LP, or LLC).
22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.)
Frontier Park Improvement Project 2018
TCEQ-10400 (04/15) Page 1of 2
23. Street Address of the
1804 Frontier Trail
Regulated Entity:
(No PO Boxes)
State
Nearest ZIP Code
City
Round Rock
State
TX
ZIP
78681
ZIP+4
7443
24. County
Williamson
Enter Physical Location Description if no street address is provided.
25. Description to
Physical Location:
North on 1-35 from Austin. Take exit 251-252A toward -35 Bus/McNeil Rd Merge onto Frontage Rd and tum left onto
Hesters Crossing Rd. Turn right onto Dry Creed Dr, left onto Old W Dr, and right onto Frontier Trail. Site on left.
26. Nearest City
State
Nearest ZIP Code
Round Rock
TX
78664
27. Latitude (N) In Decimal:
30.492054 28. Longitude (W) In Decimal:
97.687146
Degrees
Minutes
Seconds Degrees
Minutes
Seconds
30
29
31.4 97
41
13.7
29. Primary SIC Code (4 digits) 30. Secondary SIC Code (4 digits) 31. Primary NAICS Code 32. Secondary NAICS Code
5 or 6 di its 5 or 6 di its
❑ Title V Air
❑ Tires
❑ Used Oil
33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.)
Outdoor Recreation - Park
34. Mailing
Address:
❑ Waste Water
❑ Wastewater Agriculture
City
❑Other:
State
ZIP
ZIP +4
35. E -Mail Address: kbaker@roundrocktexas.gov
36. Telephone Number
37. Extension or Code
38. Fax Number (if applicable)
( 512 ) 218 - 5540
( 512 ) 218 - 5548
39. TCEQ Programs and ID Numbers Check all Programs and write in the permits/registration numbers that will be affected by the updates submitted on this form- See the Core Data
Form instructions for additional guidance.
❑ Dam Safety
❑ Districts
❑ Edwards Aquifer
❑Emissions InventoryAir
❑Industrial Hazardous Waste
(12) 18 410
Signature: �;
Date:
C —�
❑ Municipal Solid Waste
❑ New Source Review Air
❑ OSSF
❑Petroleum Storage Tank
❑ PWS
❑ Sludge
❑ Storm Water
❑ Title V Air
❑ Tires
❑ Used Oil
❑ Voluntary Cleanup
❑ Waste Water
❑ Wastewater Agriculture
❑ Water Rights
❑Other:
SECTION IV: Preparer Information
40. Name: Katie Baker 41, Title: Parks Development Manager
42. Telephone Number 43. Ext./Code 44. Fax Number 45. E -Mail Address
L ( 512 ) 218 - 5540 1 ( 512 ) 218 - 5547 I kbaker@roundrocktexas.gov
SECTION V: Authorized Signature
46. By my signature below, I certify, to the best of my knowledge, that the information provided in this form is true and complete, and that I have signature authority
to submit this form on behalf of the entity specified in Section Il, Field 6 and/or as required for the updates to the ID numbers identified in field 39.
Company: City of Round Rock
Job Title:
4Ry-M"ago; A%34-.
Name(InPrint): y IS &,J, A_,,,tl
Phone
(12) 18 410
Signature: �;
Date:
C —�
TCE4, ,Ali -4/15) _ s / ( & Page 2 of 2
City of Round Rock
ROUND ROCK Agenda Item Summary
Agenda Number:
Title: Consider executing TCEQ Core Data Form regarding the Frontier Park
Improvement Project 2018
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 4/13/2018
Dept Director: Rick Atkins, Director
Cost: $0.00
Indexes: 2014 General Obligation Bonds
Attachments: LAF - TCEQ Core Data Form for the Frontier Park Improvement Project
2018. (00399036xA08F8).pdf, Backup TCEQ Core Data Form.pdf
Department: Parks and Recreation Department
Text of Legislative File CM -2018-1686
Consider executing TCEQ Core Data Form regarding the Frontier Park Improvement
Project 2018
The Frontier Park Improvement Project is located over the Edwards Aquifer Recharge
Zone. In order to proceed with construction of the proposed park improvements
(basketball court seating, pavilion, looping trail, and park amenities) the City is filing and
Exception Request with the Texas Commission on Environmental Quality. Signature by
the City Manager is required for the application to complete the Core Data Form.
City of Round Rock Page 1 Printed on 4/1212018