CM-2018-1752 - 6/15/2018Section 14. Signature Page (Instructions Page 39)
Permit Number: W00010264001
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 § 30S.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: City Manager
(use niue uuc)
Subscribed and Sworn to before me by the said U'Vi . �(fcv
on this- 111t)day of LL , 20
My commission expires on the 920,iG4ay of G , 20 2Z-
+;o�p,QtY
Notary Publi '
4 �
•
i •
r • L� CO
County, Texas 4i1111 ... LkN
If co -applicants are necessary, each entity must submit an original, separate signature
page.
6M -2-v Ie (-7 S2
TCEQ-10053 (o6/ot/2017) Municipal Wastewater Application Administrative Report
Page 13 of 23
Section 1/ 1 Accreditation (Instructionsi
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: Michael Thane
Title: Director of Utilities and Environmental Services
Signature: -
Date: 4-11-4
TCEQ-10054 (06/01/2017) Page 20 of 80
Domestic Wastewater Permit Application, Technical Reports
M_
TCEQ Use Only
1" TCEQ Core Data Form
TC
For detailed instructions regarding completion of this form, please read the Core Data f=orm Instructions or call 512-239-5175
SECTION I: 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.)
❑x Renewal (Core Data Form should be submitted with the renewal form) ❑ Other
2. Customer Reference Number (if issuedl 3. Regulated Fntitv RPferenrP NnmhPr rif issuprtl
CN 600413181
SECTION II: Customer Information
Fallow this link to search
for CN or RN numbers in RN 100822592
Central Registry**
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 Le -gal 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)
City of Round Rock
7, TX SOSICPA Filing Number
8. TX State Tax ID t1 d -sits)
9. Federal Tax ID (9 digits)
10. DUNS Number (ifappitnel
11. Type of Customer:
I ❑ Corporation
❑ Individual
Partnership: ❑ General El Limited
Government: p city ❑ County ❑ Federal ❑ state❑other
❑ Sale Proprietorship
❑ Other.
12. Number of Employees
❑0-20 M21-100 ❑101-250 ❑251-500 ❑501 and higher
13. f ndependently Owned and Operated?
1 ❑ Yes ❑X No
14. Customer Role (Proposed or Actual) - as it relates to the Regulated Entity listed on this form. Please check one of the following
❑X Owner ❑ Operator ❑ Owner & Operator
110ccupational Licensee ❑ Responsible Party ❑ Voluntary Cleanup Applicant []Other.
221 E. Main Street
15. Mailing
Address:
City
Round Rock State
I TX ZIP
78664
ZIP+4
4410
16. Country Mailing Information if outside usA
17. E -Mail Address (if applicable)
18. Telephone Number
( 512 ) 218 - 5410
19. Extension or Code
20. Fax Number (if applicable)
( 512 ) 218 - 7097
SECTION III: Regulated Entity Information
21. General Regulated Entity Information (If 'New Regulated Entity" is selected below this forms 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 maybe updated in order to meet TCEQ Agency Data Standards (removal
of organizational endings such as Inc, LP, or LLC).
22. Regulated Entity Name (I=nter name of the site where the regulated action is taking place,)
Brushy Creek Wastewater Treatment Facility - West Plant
TCEQ- 10400 (04115) Page 1 of 2
23. Street Address of the
Regulated Entity:
(No PO Boxes)
1114 East Austin Avenue
❑ Edwards Aquifer
City
I Round Rock
State
TX
ZIP
78664
ZIP + 4
1 4410
24. County
Williamson
Enter Physical Location Description if no street address is provided.
25. Description to
Physical Location:
❑ Districts
❑ Edwards Aquifer
26. Nearest City
❑Industrial Hazardous Waste
Stale I Nearest ZIP Code—
Round Rock
18 -1
TX 78664
27. Latitude (N) In Decimal:
❑ Municipal Solid Waste
28. Longitude (W)
In Decimal.
[:]Petroleum Storage Tank
Degrees
I Seconds
D reel
Minutes
Seconds
30 30
50
97
❑ Tires
39
58
29. Primary SIC Code (4 digits) 30. Secondary SIC Code (4 digits)
31. Primary NAICS Code 32 Secondary NAICS Code
5 or 6 digits) 5 or 6 di its
4952
T 1221320
❑ Voluntary Cleanup
❑X Waste Water
❑Wastewater Agriculture
33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description)
E] Other
This facility predominantly treats domestic wastewater,
WQGO10264001
34 Mailing
Address -
22008 Enterprise Drive
City
Round Rock
State
TX
ZIP
1 78664
ZIP+4
5271
35. E -Mail Address mthane@roundmcktexas.gov
36. Telephone Number 37. Extension or Code
38. Fax Number (if applicable)
( 512 ) 218 - 3236 NIA
( 512 ) 218 - 5563
39. TCEQ Programs and ID Numbers Check all Programs and write in the permitslregistration 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 Inventory Air
❑Industrial Hazardous Waste
Ljoe Hadley
Phone(12)
18 -1
Signature:
❑ Municipal Solid Waste
❑New Source Review Air
❑ OSSF
[:]Petroleum Storage Tank
❑ PWS
❑ Sludge
❑X Storm Water
❑ Title V Air
❑ Tires
❑ Used Oil
TXR05N605
❑ Voluntary Cleanup
❑X Waste Water
❑Wastewater Agriculture
❑ Water Rights
E] Other
WQGO10264001
SECTION IV: Preparer Information
40. Name: 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 - 2145 1 1 ( 512 ) 452 - 2325 11gonzalez@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 II, Field 6 and/or as req&red for the updates to the ID numbers identified in field 39.
Company,
City of Round Rock
Job Title:
CityManager
Name(in Print)
Ljoe Hadley
Phone(12)
18 -1
Signature:
Dale.
TCEQ-10400 (04115) Page 7 of 2
City of Round Rock
TaXNQROCK Agenda Item Summary
Agenda Number:
Title: Consider executing TCEQ Permit Application regarding the Brushy Creek
Regional System East Wastewater Treatment Plant permit
amendementlrenewal.
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 -2018-9752
Consider executing TCEQ Permit Application regarding the Brushy Creek Regional
System East Wastewater Treatment Plant permit amendementlrenewal.
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 previously been awarded the job of
preparing and submitting the permit application, and an application has already been
submitted on behalf of all of 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 additional changes were going to be needed to be made at a later date, and
that the application would have to go through a significant administrative review period as
City of Round Rock Page 1 Printed an GH412018
Agenda Item Summa Continued CM -2018.1752
well.
City of Round Rock Page 2 Pdated on 8!14/2018