CM-2018-1751 - 6/15/2018Section 14. Signature Page (Instructions Page 39)
Permit Number: W00010264002
Applicant: City of Round Rock
Certification:
I certify under penalty of law that this document and all attachments were prepared under my
direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of the
person or persons who manage the system, or those persons directly responsible for gathering
the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware there are significant penalties for submitting false
information, including the possibility of fine and imprisonment for knowing violations.
I further certify that I am authorized under 30 Texas Administrative Code § 305.44 to sign and
submit this document, and can provide documentation in proof of such authorization upon
request.
Signatory name (typed or printed): Laurie Hadley
Signatory title: Ci_, _Manager
Signature:
(Use blue ink)
N
4
Subscribed and Sworn to before me by the said
on thisJ'— day of , 2 .
My commission expires on the day of (h Lel ,207-6
County, Texas
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If co -applicants are necessary, each entity must submit an original, separate signature
page.
PCE2-o(Y-l7S-I-10053 (o6/oi/2oI7) Municipal wastewater Application Administrative Report
Wage 13 of 23
Section 14. Laboratory Accreditation (Instructions Page 64)
All Iaboratory tests performed must meet the requirements of 30 TAC Chapter
25, Environmental Testing Laboratory Accreditation and Certification, which
includes the following general exemptions from National Environmental
Laboratory Accreditation Program (NELAP) certification requirements:
The laboratory is an in-house laboratory and is:
o periodically inspected by the TCEQ; or
o located in another state and is accredited or inspected by that
state; or
o performing work for another company with a unit located in the
same site; or
o performing pro bono work for a governmental agency or charitable
organization.
The laboratory is accredited under federal law.
The data are needed for emergency -response activities, and a laboratory
accredited under the Texas Laboratory Accreditation Program is not
available.
The laboratory supplies data for which the TCEQ does not offer
accreditation.
The applicant should review 30 TAC Chapter 25 for specific requirements.
The following certification statement shall be signed and submitted with every
application. See the Signature Page section in the Instructions, for a list of
designated representatives who may sign the certification.
CERTIFICATION:
I certify that all laboratory tests submitted with this application meet the
requirements of 30 TAC Chapter 25, Environmental Testing Laboratory
Accreditation and Certification.
Printed Name: Laurie Hadley
Title: City Manager. City of Round Rock
Signature: Gw?�
Date:' �'✓ ' tg
TCEQ 10054 (06/01/2017) Page 20 of $0
Domestic Wastewater Permit Application, Technical Reports
NNW TCEQ Use Only
T TCEQ Core Data Form
For detailed instructions regarding completion of this form, please read the Core Data Form Instructions or call 512-239-5175.
SECTION E: General Information
1. Reason for Submission (If other is checked please describe in space provided.)
❑ 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 ❑x other Major Amendment with Renewal
2. Customer Reference Number if issued Follow this link to searchr:RN
R ulated Entit Reference Number if issuedCN 600413181 for CN or RN numbers in 100822600
SECTION II: Customer Information a
4, General Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership
❑Chan a 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, pant last name first a g. Doe, John) It now Customer, enter previous Customer below:
City of Round Rock
7. TX SOSlCPA Filing Number
8. TX Slate Tax ID 0 t aigi'i
9. Federal Tax ID (9 dots)
10. DUNS Number (if appticabie)
11. Typ2 of Customer:
❑ Corporation
❑ Individual
Partnership: ❑ General [I limited
Government: ❑x City ❑ County El Federal ❑ Slate❑Other
❑ Sole Proprietorship
❑ Other:
12. Number of Employees
❑0-20 M21-100 ❑101-250 ❑251-500 ❑501 and higher
13, Independently Owned and Operated?
❑ Yes ❑ No
14. Customer Role (Proposed or Actual) - as it relates to the Regulaled Entity listed on this form. Please check one of the following:
Downer ❑ Operator ❑ Owner & Operator
❑Occupational Licensee ❑ Responsible Party ❑ Voluntary Cleanup Applicant ❑Other.
Mailing
212 E. Main Street
15.
Address:
City Round Rock
State
I TX
ZIP
178664 ZIP + 4
16. Country Mailing Information if outside USA
17. E -Mail Address if applicable)
Ihadley@roundrocktexas.gov
18. Telephone Number
(512 ) 218 - 5410
19. Extension or Code
F11axumber (if applicable)
218-7097
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)
❑ 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,)
Brushy Creek Wastewater Treatment Facility - East Plant
TCEQ-10400 (04115) Page Sof 2
23. Street Address of the
Regulated Entity:
(No PO Boxes)
3939 E Palm Valley Blvd
❑ Edwards Aquifer
City I Round Rock
I State
I TX
I ZIP 78665
=ZIP+4
I
24. County
Williamson
Enter Physical Location Description if no street address is provided.
25. Description to
Physical Location:
❑ Districts
❑ Edwards Aquifer
❑Emissions Inventory Air
26. Nearest C61
I Laude Hadley -
State I Nearest ZIP Code
Round Rock
I
TX 178664
27. Latitude (N) In Decimal:
30.526583
❑ OSSF
28. Longitude (W)
In Decimal: -97.620733
Degrees
Minutes Seconds
_Degrees
Minutes I Seconds
Storm Water
❑ Title V Air
❑Tires
❑ Used Oil
TXR05L921
29. Primary SIC Code (4 digits) 30. Secondary SIC Code (4 digits)
31. Primary NAICS Code 32. Secondary NAICS Code
5 or 6 d' its 5 or 6 di its
4952
T
221320
❑Wastewater Agriculture
❑ Water Rights
33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.)
The facility primarily treats
domestic wastewater.
34. Mailing
Address:
2008 Enterprise Drive
city
Round Rock
State
TX
ZIP
78664 ZIP + 4
35. E -Mail Address: mthane@roundrocklexas.gov
36. Telephone Number
37. Extension or Code
38. Fax Number (if applicable)
( 512 ) 218 - 3236
( 512 ) 218 - 5563
39. TCEQ Programs and ID Numbers Check all Programs and write in the permitshegistrabon numbers that will be affected by the updates submitted on this form. See the Core Data
Form instructions for additional guidance.
❑ Dam Safely
❑ Districts
❑ Edwards Aquifer
❑Emissions Inventory Air
[:]Industrial Hazardous Waste
I Laude Hadley -
Phone:
(12) 18 - 410'
Signature:
Date:
❑ Municipal Solid Waste
New Source Review Air
❑ OSSF
❑Petroleum Storage Tank
❑ PWS
❑ SludgeX❑
Storm Water
❑ Title V Air
❑Tires
❑ Used Oil
TXR05L921
❑ Voluntary Cleanup
X❑ Waste Water
❑Wastewater Agriculture
❑ Water Rights
❑other.
WQ0010264002
SECTION IV: PreDarer Information
40. Name: I Lauren E. Gonzalez 41. Title: Project Manager, Alan Plummer Assoc., Inc.
42. Telephone Number 43. Ext./Code 44. Fax Number 45. E -Mail Address
( 512 ) 687 - 5905 1 1 ( 512 ) 452 - 2325 ligonzak@apalenv.com
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 11, Field 6 andlor as required for the updates to the ID numbers identified in field 39
Company:
City of Round Rock
Job We
City Manager
Name(fnP&Q:
I Laude Hadley -
Phone:
(12) 18 - 410'
Signature:
Date:
_/_S_/
A
TCEQ.10400104)15} Page 2 of 2
City of Round Rock
RouNORocK Agenda Item Summary
DEXA
Agenda Number:
Title: Consider executing TCEQ Permit Application regarding the Brushy Creek
Regional System West Wastewater Treatment Plant permit
amendment/renewal.
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 6/15/2018
Dept Director: Michael Thane, Director of Utilities and Environmental Services
Cost:
Indexes:
Attachments: Agmt.pdf, LAF.pdf
Department: Utilities and Environmental Services
Text of Legislative File CM -2018-9751
Consider executing TCEQ Permit Application regarding the Brushy Creek Regional
System West Wastewater Treatment Plant permit amendment/renewal.
The Texas Commission on Environmental Quality (TCEQ) reviews and issues all
wastewater discharge permits for wastewater treatment facilities in the State in the form of
TPDES permits. They also issue the permits on behalf of the EPA in the form of an
NPDES. The current permit for the plant expires in December of this year and under
TCEQ rules the renewal applications must be submitted at least 180 days before
expiration.
Alan Plummer and Associates, Inc. (APAI) has been working on preparing and submitting
the permit application, and an application has already been submitted on behalf of all the
partner cities by APAI. Since the Cities of Austin, Cedar Park, and Round Rock are all
co-permitees on the permit in the regional system, all three cities must submit signature
pages signed by a person authorized to sign the application. Currently, the only persons
authorized to sign on behalf of Round Rock are either the Mayor or the City Manager.
Placeholder signature pages were submitted with the application knowing that the
application would have to go through an administrative review period during such time the
original signature pages could be inserted.
City of Round Rock Page i Printed on A/14/2aie