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CM-2024-217 - 8/23/2024SWINE XEG TEXAS COMMISSION ON ENVIRONMENTAL QUALITY APPLICATION TO TRANSFER A WASTEWATER PERMIT OR CAFO PERMIT If you have questions about completing this form please contact the Applications Review and Processing Team at 512-239-4671• SECTION 1. CURRENT PERMIT INFORMATION What is the Permit Number? W 001026 001 What is the EPA I.D. Number? TX ows167 What is the Current Name on the Permit? Brushy Creek Regional West Wastewater Treatment. Plant What is the Customer Number (CN) for the current permittee? CN60041i18i, CN600i3Si98, and CN6004wosi What is the Regulated Entity Reference Number (RN): RN ioo822S02 For Publicly Owned Treatment Works (POTWs) Only: a) Does this permit require implementation of an approved pretreatment program by the POTW? Yes E No b) Does this permit have a domestic reclaimed water authorization associated with it? NOTE. The domestic reclaimed water authorization associated with this permit will be cancelled on the same date the transfer took place. See instructions for more information. Yes 0 No Ll SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION A. What is the Legal Name of the facility owner? City of Round Rock B. What is the Customer Number (CN) issued to this entity? CN 6004m8i C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. i0o-Z�Pt/�/L-7 TCEQ -20031 (10/20/2017) Application to Transfer Wastewater Permit or CAFO Permit Page ? SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION D. What is the Legal Name of the facility owner? City of Austin E. What is the Customer Number (CN) issued to this entity? CN 600i3s198 F. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION G. What is the Legal Name of the facility owner? City of Cedar Park H. What is the Customer Number (CN) issued to this entity? CN 600407951 I. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 3. CO -APPLICANT INFORMATION Complete this section only if another person or entity is required to apply as a co-permittee. A. What is the Legal Name of the co -applicant applying for this permit? NJA B. What is the Customer Number (CN) issued to this entity? CN NSA C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 4. APPLICATION CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed about this application. Application Contact First and Last Name: Ashley Lewis Title: Water Quality/ Permitting Team Leader Credentials: N/A Company Name: Plummer Associates, Inc. Mailing Address: 8911 N Capital of Texas Hwy, Bldg 1— Ste 1250 City, State, and Zip Code: Austin, Texas 787s4 Phone Number: 512-687-2154 Fax Number: NLA E-mail Address. alewis(@plummer.com TCEQ -20031 (10120/2017) page 2 Application to Transfer Wastewater Permit or CAFO Permit SECTION S. PERMIT CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed during the term of the permit. Permit Contact First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: City of Round Rock Mailing Address: g400 Sunrise Rd City, State, and Zip Code: Round Rock, TX 7866s Phone Number: 512-218-5236 Fax Number: N A E-mail Address: mthane@roundrocktexas.gov SECTION 6. SITE INFORMATION Site Name: Brushy Creek Regional West Wastewater Treatment Plant SECTION 7. LEASE AND EASEMENT REQUIREMENTS A. Landowner where the facility is or will be located: Landowner Name: City of Round Rock If this individual is not the same person as the facility owner or co -applicant, attach one of the following documents: • A lease agreement or deed recorded easement, if the facility is NOT a fixture of the land, or A deed recorded easement if the facility IS a fixture of the land. B. Landowner of the effluent disposal site: Landowner Name: If this individual is not the same person as the facility owner or co -applicant, attach a lease agreement. C. For CAFOs: Attach the following records: • Warranty Deed or Property Tax Records • Lease Agreement (for land management units that are not owned by the facility owner or co -applicant) Facility Size on the proof of ownership, in acres: N A TCEQ-20031 (1012012017) Page 3 Application to Transfer Wastewater Permit or CAFO Permit SECTION 8. TRANSFER DATE What is the date that the transfer of operator or ownership will occur? 11/1212024 SECTION 9. REPORTING AND BILLING INFORMATION A. Please identify the individual for receiving the reporting forms. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: Cijy of Round Rock Mailing Address:.moo Sunrise Rd City, State, and Zip Code: Round Rock, TX 7866s Phone Number: S,12-218-32�6 Fax Number: N A E-mail Address: mthaneoroundrocktexas.gov B. Please identify the individual for receiving the annual fee invoices. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Company Name: City of Round Rock Mailing Address: 3400 Sunrise Rd City, State, and Zip Code: Round Rock, TX 78665 Phone Number: 512-218-.Q6 Fax Number: N A E-mail Address: mthanegroundrocktexas.gov SECTION 10. DELINQUENT FEES OR PENALTIES Do you owe fees to the TCEQ? Yes ❑ No Do you owe any penalties to the TCEQ? Yes ❑ No Credentials: P.E. If you answered yes to either of the above questions, provide the amount owed, the type of fee or penalty, and an identifying number. NLA TCEQ -20031 (1012012017) Par. a Application to Transfer wastewater Permit or CAFO Permit TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Laurie Hadley Title: City Manager, City of Round Rock Signature: GG � Date: t�)5' a SUBSCRIBED AND SWORN to before me by the said Wion thisi day of ,�1�L-� . 20 a* My commission expires on the ay of .L N ry Public T MONIQUEADAMS ; :*? My Notaq II_D.## 1226�2679113 EVIta March 22, 2026 ! f�County, Texas TCEO -20031 (110120120W) Pa9e S Application to Transfer Wastewater Permit or CAFO Permit TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing 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.) ❑ 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) ® Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers in CN 600413181 Central Registry'• RN 100822592 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer information Updates (mm/dd/yyyy) 11/1212024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change 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 (ff an individual, print last name first: eg: Doe, John) If new Customer, enternrevious customer below: City of Round Rock 7. TX SOS/CPA Filing Number S. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 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 Regulated Entfty listed on this form Please check one of the following ❑Owner ❑ Operator ® Owner & Operator ❑ Other: ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Appiicant 15. Mailing Address: 212 East Main Street City Round Rock State Tx ZIP 1 78664 ZIP + 4 5245 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) lhadieV@roundrock-texas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 1 512 ) 218-5410 I I 1 512 ) 218-7097 SECTION III: Regulated Entity 21. General Regulated Entity Information (if New Regulated Entity' is selected, a new permit application is also required.) ❑ 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 Care Data Standards (removal of organizational endings such as Inc, LP, or LLQ. 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional West Wastewaster Treatment Facility 23. Street Address of 1116 East Austin Avenue the Regulated Entity: (No PO Boxes) City Round Rock State 7X ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78664 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes &mands 30 30 50 97 49} 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) (5 or 6 digits) {5 or 6 digosl 4952 221320 33. What is the Primary Business of this entity? (Donor repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City I Round Rock State TX ZIP 1 78665 ZIP + 4 2.398 3S. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (¢applfcuh)r) 1512 ) 228-3236 (512 ) 218-5563 39. TCEQ Programs and ID Numbers Check all Programs and write in the permits/registration numbers that w1 be affected by the updates submitted on this form. See the Core Data Form instructions for additional guidance. TCEQ40400 (11122) Page 2 of 3 Dam Safety ❑ Districts Edwards Aquifer Emissions Inventory Air 0 Industrial Hazardous Waste ❑ Municipal Solid Waste ❑ New SourceReview Air ❑ OSSF ❑Petroleum Storage Tank ElPWS LI Sludge Storm Water Title V Air ❑ Tires U Used Oil ❑ Voluntary Cleanup ® Wastewater ❑ Wastewater Agriculture ❑ Water Rights ❑ Other: W00010264001 SECTION IV: Preoarer Information 40. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address (512) 687-2193 ( ) jgriesel@plummer.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 required for the updates to the ID numbers identified in field 39. Company: City of Round Rock Job Title: City Manager Name fin Print): Laurie Hadley Phone: (512) 218- 5410 Signature:%r/ 7 7 Q Date: gyp; TCEO-10400 (11122) Page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Shay Ralls Roalson Title: Director of Austin Water, CijX of Austin %UVjq.�JA& Signature: _a°�°�-� Date: Z� SUBSCRIBED AND SWORN to before me by the said 5!K R4IS_ Ro45dn _on this 1st day of � t�j .202q My commission expires on the S+ day of J LMel , 2Q�L E BORAH l OCKIETNEE 1085173787 =tsston Exptresjme21,202i "wor _ _ Notary Public Page B TCEQ •20031 {1012(12017) Application to Transfer Wastewater Permit or CAFQ Pen -rut TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing this form, please read the Core Data Form Instructions or call 512-239-5175. SECTION I: General Information 1. Reason for Submission (lf 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) Q9 Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers in CN 600135198 Central Reftistry" RN 100822592 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership ❑Change 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 (CAA). 6. Customer Legal Name (if an individual, print last name first: eg: Doe, John) if new Customer enter orevious Customer below: City of Austin 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ® 501 and higher 13. Independently Owned and Operated? ❑ Yes ® No 14. Customer Role (Proposed of Actual) —os it relates to the Regulated Entity listed on this form. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant ❑Other: 15. Mailing Address: 625 East 10th Street Suite 800 City I Austin State Tx ZIP 78701 ZIP + 4 1 2612 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) shay.roalson@austintexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 I( 512 ) 972-0108 I I ( 512 1 972-0111 I SECTION III: Regulated Entity Information 21. General Regulated Entity Information (If New Regulated Entity" is selected, anew permit application is also required) ❑ 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 Core 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 Regional West Wastewaster Treatment Facility 23. Street Address of the Regulated Entity: (No PO Boxes? 1116 East Austin Avenue City Round Rock State TX ZIP 78664 ZIP+4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78664 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 50 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) (5 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing 3400 Sunrise Road Address: City Round Rock State TX ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512 ) 219-3236 (512 ) 218-5563 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 th's form. See the Core Data Form instructions for additional guidance. TCEQ-10400 (11I22) Page 2 of 3 Dam Safety U Districts Edwards Aquifer Emissions inventory Air Industrial Hazardous Waste ❑ Muni[ipWaste New SourceReviewSolid Review Air ❑ OSSF ❑Petroleum Storage Tank Q PWS Sludge Storm Water Title V 'AirTires 0 Used 0 1 Volunlary Cleanup 0 Wastewater ❑ Wastewater Agriculture water Rights ❑ Other WQW1020001 _ 6 1 _ r 1 s 11 r IT r 1 40. Name: lenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address 1 512) 687-1193 l 1 Igriese'-ftlummertom 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 s gnat ure author ty to submit this form on behalf of the entity specified in Section R, Fleld 6 and/or as required for the updates to the ID numbers identified in field 39 Companv. " - Gdy of Austin Name (in Print): I Shay Rails Roalson Signature: Job �Ie— Director of Austin Water Phone: (5121972•0108 T i Date: TGEQ-10400 (11f22) page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Brenda Eivens Title: City Manager, City of Cedar Park Signature: Date: SUBSCRIBED AND SWORN to before me by the said on this day ME My commission expires on the day of , 20 (Seal) Notary Public TCEQ .20031 (10/20/2017) Page 7 Application to Transfer Wastewater Permit or CAFO Permit TCEQ Use Only � V TCEQ Core Data Form For detailed instructions an completing this form, please read the Core Data Form Instructions or call 512-239-5175- SE TION I: General Information I. 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.) QCJ Renewal (Core Data Form should be submitted with the renewal form) R9 Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers in CN 600407951 Central Rexistrv** RN 100822592 SECTION II: Customer Information 4. General Customer Information r.Effective Date for Customer Information Updates (mm/dd/WW) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change 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 lost name first: eg: Doe, John) if new Customer enter previous Customer below: City of Cedar Park 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax iD (9 digits) 10. DUNS Number {if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ Genpral ❑ -imrpd Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 101-250 ® 251-500 ❑ 501 and higher 23. 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 foltpwing ®Owner ❑ Operator ❑ Owner & Operator ❑ Other- ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant 15. Mailing Address: 450 Cypress Creek Road Bldg 1 City Cedar Park State TX ZIP 78613 ZIP + 4 s r 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) brenda.e'ivens@cedaiparktexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if opplicable) TCEQ-10400 (11122) Page 11 of 3 1 512 ) 401-5010 ( 512 ) 250-8602 SECTION III; Regulated Entity Information 21. General Regulated Entity Information (if 'New Regulated Entity" is selected, anew permit application is also required.) ❑ 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 Core Data Standards (removal of organizational endings such as inc, 1P, or LLQ. 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional West Wastewaster Treatment Facility 23. Street Address of the Regulated Entity: 1116 East Austin Avenue &oP0Boxes l City Round Rock State TX ZIP 78664 ZIP +4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78664 Latftude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 so 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) (5 or 6 digits) (S or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (00 not repeat the SEC or NAICS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City I Round Rock State TX ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.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 permits/registration numbers that will be affected by the updates submitted on this form. See the Core Data Form instructions for additional guidance. TCEQ-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer 11 Emissions Inventory Air Industrial Hazardous Waste Municipal Solid Waste El Municipal ❑ Source Review Air ❑ OSSF ❑Petroleum Storage Tank ❑ PW5 Sludge Storm Water Title V Air ❑ Tires Used Oil ❑ voluntary Cleanup ® Wastewater ❑ Wastewater Agriculture ❑ Water Rights ❑ Other: WQ0010264001 i I SECTION IV: Preparer Information 40. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address ( 512 ) 687-2193 { j igriesel@plummer-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 required for the updates to the ID numbers identified in field 39. Company: City of Cedar Park Job Title: City Manager Name (in Print): Brenda Eivens Phone: { 512 i 4D1- 5010 Signature: --...---------- {Dater---- — — TCEO-10400 (11122) Page 3 of 3 TRANSFEREE SIGNATURE (New Facility Owner) I certify that a change of ownership of the facility for the subject permit has been issued will occur as indicated in the application. As a condition of the transfer, I do hereby declare that: The transferee will be the owner of the existing treatment facility from which wastewater is discharged, deposited or disposed or the facilities required to comply with the permit will be constructed as described in the application considered by the TCEQ prior to the issuance of the permit. The transferee possesses a copy of the permit, understands the terms and conditions therein, and does accept and assume all obligations of the permit. The transferee assumes financial responsibility for the proper maintenance and operation of all waste treatment and disposal facilities required by the permit or which may be required to comply with the permit terms and conditions. The transferee certifies that the transfer is not made for the purpose of avoiding liability for improper actions carried out prior to the date of transfer. Neither is the transfer made for the purpose of transferring responsibility for improper operations to an insolvent entity. The transferee certifies under penalty of law that this document 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 known violations and revocation of this permit. New Facility Owner: Todd Parton Title: Ci1y Mang Signature: Date:TYd��� SUBSCRIBED AND SWORN to before me by the said 1 eddt 494f) on this Sow= day of My commission expires on the 0 day of 20 �$ County, Texas TCEO -20034 (10/M017) Application to Transfer wastewater PermR or CAFo Permit Page 9 {4M MlgslaTCEQ Use Only 4ty h'Mf NTNLTCEQ Core Data Form For detailed instructions on completing 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.) ❑ New Permit, Registration or Authorization (Core Data Form should be submitted with the program application.) N Renewal (Core Data Form should be submitted with the renewal form) Ug Other Change in Ownership 2. Customer Reference Number (if issued) Fallow (bib link to search 3. Regulated Entity Reference Number (ifissued) for CN or RN numbers in CN 600646022 Central Registry" RN 100822592 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change 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: eg: Doe, John) if new Customer, enter previous Customer below: City of Leander 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 0 101-250 ❑ 251-500 ❑ 501 and higher 13. Independently Owned and Operated? ❑ Yes ® No 14. Customer Role (Proposed or Actual) —as it relotes to the Regulated Entity listed on this form. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator []Occupational licensee [I Responsible Party ❑ VCP/BSA Applicant ❑Other: 1S. Mailing 201 N. Brushy Street Address: City Leander State TX ZIP 78641 ZIP + 4 16. Country Mailing Information (if outside USA) 17. E-Ma]l Address (if applicable) N/A iturner@leandertx.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 111122) Page 1 of 3 1 512 ) 528-2919 SECTION III: Regulated _Entity_ -Information 21. General Regulated Entity Information (if New Regulated Entity" is selected, a new permit application is afso required.) ❑ 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 Core Data Standards (removal of organizational endings such as Inc, LP, or LLQ. 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional West Wastewaster Treatment Facility 23. Street Address of the Regulated Entity: 1116 East Austin Avenue (No PO Boxes) City Round Rock State 7x ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Latitude/Longitude are required and may be added/updated to meet TCEQ Care Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 50 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) 15 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City Round Rock State Tx ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512) 219-3236 1 512 ) 218-5563 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. Seethe Core Data Form instructions for additional guidance. TCEQ-10400 (11122) Page 2 of 3 Oam Safety Ej 0-stricts Edwards Aquifer Emissions inventory Air Industrial Hazardous Waste © Municipal Solid Waste New Source Review Air OSSF ❑ Petrpleum Storage Tank ❑ PWS Sludge C1 Storm Water Title V Au Tires used Or Voluntary Cleanup 0 Wastewater Wastewater Agriculture U Water Rights Other: WQOD20264001 114 Ik k t i ti. r l 40. Name: lennm Gnesel 41. Title: Project Engineer 42. Telephone Number 43. ExL/Code 44. Fax Number 45. &Mell Address I S12 j (87.2193 l igries Oplummer tom SECTION : Authorized Sire 46. By my signature below. I certify, to the best of my knowledge, that the Information provided in th s form is true and complete, and that I have signature authority to submit this form on behalf of the entity specified In Section % Field 6 and/or as requited For the updates to the ID numbers identified in field 39 compo9: City of Leander lob Title: City Manager Name ton Pfmt) Todd Parton I Phone: (512 )528• Z9Z9 Signature: Date: I y TMO.10400 (11122) Page 3 of 3 AC XEG TEXAS COMMISSION ON ENVIRONMENTAL QUALITY APPLICATION TO TRANSFER A WASTEWATER PERMIT OR CAFO PERMIT If you have questions about completing this form please contact the Applications Review and Processing Team at 512-239-4671• SECTION 1. CURRENT PERMIT INFORMATION What is the Permit Number? W0001026400l What is the EPA I.D. Number? TX oo75167 What is the Current Name on the Permit? Brushy Creek Regional West Wastewater Treatment Plant What is the Customer Number (CN) for the current permittee? CN600413181, CN6o0135198, and CN6004079-51 What is the Regulated Entity Reference Number (RN): RN 100822592 For Publicly Owned Treatment Works (POTWs) Only: a) Does this permit require implementation of an approved pretreatment program by the POTW? Yes ® No ❑ b) Does this permit have a domestic reclaimed water authorization associated with it? NOTE: The domestic reclaimed water authorization associated with this permit will be cancelled on the same date the transfer took place. See instructions for more information. Yes ® No ❑ SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION A. What is the Legal Name of the facility owner? City of Round Rock B. What is the Customer Number (CN) issued to this entity? CN 6o0413181 C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. TCEQ -20031 (1012012017) Page Application to Transfer Wastewater Permit or CAFO Perm t SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION D. What is the Legal Name of the facility owner? City of Austin E. What is the Customer Number (CN) issued to this entity? CN 600vi5198 F. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION G. What is the Legal Name of the facility owner? City of Cedar Park H. What is the Customer Number (CN) issued to this entity? CN 6004o7c)51 I. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 3. CO -APPLICANT INFORMATION Complete this section only if another person or entity is required to apply as a co-permittee. A. What is the Legal Name of the co -applicant applying for this permit? B. What is the Customer Number (CN) issued to this entity? CN NA C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 4. APPLICATION CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed about this application. Application Contact First and Last Name: Ashley Lewis Title: Water Quality/ Permitting Team Leader Credentials: NLA Company Name: Plummer Associates, Inc. Mailing Address: 8911 N Capital of Texas Hwy, Bldg 1 Ste 12So City, State, and Zip Code: Austin, Texas 787SA Phone Number: 512-687-2154 Fax Number: NIA E-mail Address: alewis@plummer.com TCEQ 20031 (10/2012017) Page 2 Application to Transfer Wastewater Permit or CAFO Permit SECTION S. PERMIT CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed during the term of the permit. Permit Contact First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: City of Round Rock Mailing Address: 3400 Sunrise Rd City, State, and Zip Code: Round Rock TX 78665 Phone Number: 51e-218-rJQ6 Fax Number: NJA E-mail Address: mthane(@roundrocktexas.g_ov SECTION 6. SITE INFORMATION Site Name: Brushy Creek Regional West Wastewater Treatment Plant SECTION 7. LEASE AND EASEMENT REQUIREMENTS A. Landowner where the facility is or will be located: Landowner Name: City of Round Rock If this individual is not the same person as the facility owner or co -applicant, attach one of the following documents: • A lease agreement or deed recorded easement, if the facility is NOT a fixture of the land, or • A deed recorded easement if the facility IS a fixture of the land. B. Landowner of the effluent disposal site: Landowner Name: NJA If this individual is not the same person as the facility owner or co -applicant, attach a lease agreement. C. For CAFOs: Attach the following records: • Warranty Deed or Property Tax Records • Lease Agreement (for land management units that are not owned by the facility owner or co -applicant) Facility Size on the proof of ownership, in acres: N A TCEQ -20031 (10120/2017) Page 3 Application to Transfer Wastewater Permit or CAFO Permit SECTION 8. TRANSFER DATE What is the date that the transfer of operator or ownership will occur? 11/12/2024 SECTION 9. REPORTING AND BILLING INFORMATION A. Please identify the individual for receiving the reporting forms. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: City of Round Rock Mailing Address: moo Sunrise Rd City, State, and Zip Code: Round Rock, TX 78665 Phone Number: 12-218- 2 6 Fax Number: NIA E-mail Address: mthane@roundrocktexas.gov B. Please identify the individual for receiving the annual fee invoices. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Company Name: City of Round Rock Mailing Address:.moo Sunrise Rd City, State, and Zip Code: Round Rock, TX 7866g Phone Number: S12-218-12g6 Fax Number: N A E-mail Address: mthane roundrocktexas.gov SECTION 10. DELINQUENT FEES OR PENALTIES Do you owe fees to the TCEQ? Yes ❑ No N Do you owe any penalties to the TCEQ? Yes ❑ No N Credentials: P.E. If you answered yes to either of the above questions, provide the amount owed, the type of fee or penalty, and an identifying number. NLA TCEQ -20031 (10/2012017) Page 4 Application to Transfer Wastewater Permit or CAFO Permit TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Laurie Hadley Title: City Manaur. City of Round Rock Signature Date: SUBSCRIBED AND SWORN to before me by the said C n this �1511�( day of , 20 My commission expires on the__.._ aide,day of _ ._Zw� , 20 (Seal) tary Public MONIQUE ADAMS _'' •i My Notary ID # 1262R913 EVW MaO 22.2026 County, Texas TCEQ -20031 (10/2012017) Application to Transfer Wastewater Permit or CAFO Permit Page h TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing 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.) ❑ 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) ® Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to sea rch 3. Regulated Entity Reference Number fifissued) for CN or RN numbers -in CN 600413181 Central Registry' RN 100822592 SECTION II: Customer Information 4. General Customer information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership []Change 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: eg: Doe, John) If new Customer, enter previous Customer below: City of Round Rock 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 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 Regulated Entity listed on this form. Please check one of the following ❑Owner ❑ Operator ® Owner & Operator ❑ Other: 00ccupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant 15. Mailing Address: 212 East Main Street City Round Rock State TX ZIP 1 78664 ZIP + 4 5245 16. Gauntry Mailing information (if outside USA) 17. E-Mail Address (if applicable) lhadley@roundrocktexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 ( 512 ) 218-5410 I - -- I ( 512 ) 218-7097 — SECTION III: Regulated Entity Information 21. General Regulated Entity Information (If New Regulated Entity" is selected, a new permit application is also required.) ❑ 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 Core Data Standards (removal of organizational endings such as lnc~ LP, or LLC). 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional West Wastewaster Treatment Facility 23. Street Address of 1116 East Austin Avenue the Regulated Entity: (No PO Boxes) City Round Rock State TX ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78664 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 5o 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) 15 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City Round Rock State TX ZIP I 7966S ZIP + 4 2398 35. E-Mail Address: mthaneeroundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) (512) 218-3236 (512 1218-5S63 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 thii form. See the Core Data Form instructions for additional guidance. TCEQ-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer 0 Emissions Inventory Air Industrial Hazardous Waste ❑ Municipal Solid Waste ❑ New SourceReview Air ❑ OSSF ❑Petroleum Storage Tank ❑ PWS Sludge storm Water TEVAi, Tires ❑ Used Oil ❑ Voluntary Cleanup ® Wastewater ❑ Wastewater Agriculture ❑ Water Rights ❑ Other: WQD010264001 SECTION IV: Preuarer Information 40. Name: Jenni Griesel 41. Title: Project Engineer 92. Telephone Number 43. Ext./Code 44. Fax Number � T45. E-Mail Address 1512) 687-2193 ( ) jgriesel@plummeccom 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 required for the updates to the ID numbers identified in field 39. Company: Name fln Print): Signature: City of Round Rock Laurie Hadley Job Title: I City Manager Phone: ( 512 } 218- 5410 Date: a r TCEO-10400 (1V22) Page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: ShU Ralls Roals9n Title: Director of Austin Water, CitYof Austin Signature: Date•, SUBSCRIBED AND SWORN to before me by the said 5�ay Rails Ron on this 36� day of J !!P� , 20 ,? y My commission expires on the Si' day of -Jl41e- , 20� �d" �� DEBORAM 1. OCKLETREE + � iD ITS173J97 y ll�lsslon Expires *?a Jane 21, 2025 Notary Public Page 6 TCEQ -20031 (1012(12017) Application to Transfer Wastewater Permit or CAFQ Petmit TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing 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.) ❑ New Permit, Registration or Authorization (Care Data Farm should be submitted with the program application.) Q9 Renewal (Care Data Form should be submitted with the renewal form) Q9 Other Change In Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN num5crs in CN 600135298 Central Registry— RN 100822592 SECTION II: Customer Information 4. General Customer Information 5. Effective Date for Customer Information Updates (mmf dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership ❑Change 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 (505) or Texas Comptroller of Public Accounts (CPA). 6. Customer Legal Name (if an individual, print last name first: eg: Doe, John) If new Customer, enter previous Customer below: City of Austin 7. TX SOS/CPA Filing Number 8, TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ® 501 and higher 13. Independently Owned and Operated? ❑ Yes ® No 14. Customer hole (Proposed or Actual) —as it relates to the Regulated Entity listed on this form. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator © Other: 00ccupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant 15. Mailing Address: 625 East loth Street Suite 800 City Austin State TX ZIP 1 78701 ZIP + 4 2612 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) shay,roalson@austintexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 ( 512 ) 972-0108 I I ( 512 ) 972.0111 I SECTION III: Regulated Entity Information 21. General Regulated Entity Information (if 'New Regulated Entity" is selected, a new permit application is also required) ❑ 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 Core Data Standards (removal of organizational endings such as Inc, LP, orLLQ. 22. Regulated Entity Name (Enter name of the site where the regulated oction is taking place.) Brushy Creek Regional west wastewaster Treatment Facility 23. Street Address of 1116 East Austin Avenue the Regulated Entity: (No P4 Boxes) City Round Rack State 7X ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 7$664 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) in Decimal: Degrees Minutet Seconds Degrees Minutes Seconds 30 30 50 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAICS Code (4 digits) (4 digits) (5 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? lu, not repeat the SIC or NAICS description.) Treatment of domestic wBsmwater 34. Mailing 3400 Sunrise Road Address: City Round Rock State TX ZIP 79665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512 ) 219-3236 ( 512) 218-5563 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. TCEQ-10400 (11I22) Page 2 of 3 0am Safety Districts Edwards Aquifer Emissi<sr s inventory Air industrial Hazardous Waste © Municipal Solid waste _ff Sourceipal Review Air ❑ 055E ❑ Petroleum Storage Park 0 PW5 Sludge Storm Water 0 Title V Air U Tires 0 Used 0 1 Voluntary Cleanup Wastewater [j Wastewater Agriculture Water Rights ❑ Other WQ0010264001 4_ rr-_U4_0_1 API 11 c ' 1 40. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address ( 5121637-2193 ( ) jgriesel@piummer.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 s gnalure author ty to submit this form on behalf of the entity specified to Section 11, Field 6 and/or as required for the updates to the ID numbers identified in held 39 I `PAY -- Uty of Austin �1- Name fln PrintJ: J ;Shayails Roalson signature: iJob Tile: O;rector of Austin Water L Phone: (512 1972. 0108 I _ _ -- Date- TCEQ-10400 (11f22) Page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Brenda Eivens Title: City Manager, City of Cedar Park Signature: Date: SUBSCRIBED AND SWORN to before me by the said this day 20 My commission expires on the day of , 20 (Seal) Notary Public TCEQ -20031 (10120/2017) Page 7 Application to Transfer Wastewater Permit or CAFO Permit }'S�orn Miss ny i s� q�hMfNTA�pJ' TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing 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) ❑ 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) ® Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued. for CN or RN numpers in CN 600407951 Central Registry" RN 100822592 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11112/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership []Change 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 lost name first: eg: Doe, John) if new Customer, enter previous Customer below: City of Cedar Park 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number ljf applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees 0.20 ❑ 21-100 ❑ 101-250 ® 251-500 ❑ 501 and higher Independently Owned and Operated? Yes ® No JCJ 14. Customer Role (Proposed or Actual) —as it relates to the Reguloted Entity listed on this form. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator ❑ Other: ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant 15. Mailing 450 Cypress Creek Road Address: Bldg 1 City Cedar Park State I TX ZIP 1 78611 ZIP +4 M)J 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) brenda.eivens@cedarparktexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number lif applicable) TCEQ-10400 (11122) Page 1 of 3 1512 ) 401-5010 I I ( 512 ) 250.8602 SECTION III: Regulated Entity- InfQrMaji,Qn. 21. General Regulated Entity Information (if New Regulated Entity" is selected, a new permit application is also required.) ❑ 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 Core 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 Regional West Wastewaster Treatment Facility 23. Street Address of 1116 East Austin Avenue the Regulated Entity: (No PO Boxes) City Round Rock State TX ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78664 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 So 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAILS Code (4 digits) (4 digits) 15 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAILS description.) Treatment of domestic wastewater 34. Mailing 3400 Sunrise Road Address: City Round Rock State TX ZIP 78665 ZIP + 4 2399 35. E-Mall Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) (512) 218-3236 1512 j 218-5563 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. TCEQ-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer Emissions Inventory Air Industrial Hazardous Waste ❑ Municipal Solid Waste New Source Review Air ❑ OSSF ❑ Petroleum Storage Tank ❑ PWS Sludge Storm Water Title V Air Tires 0 Used Oil ❑ Voluntary Cleanup ® Wastewater ❑ Wastewater Agriculture ❑ Water Rights ❑ Other: WQ0010264001 SECTION IV: Preoarer Information 40. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address (512 j 687.2193 ( ) jgriesel@plummer.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 required for the updates to the ID numbers identified in field 39. Company: City of Cedar Park Job Title: City Manager Name (1n Print): Brenda Eivens Phone: (512 ) 401- 5010 Signature: Date: TCEO-10400 (11122) Page 3 of 3 TRANSFEREE SIGNATURE (New Facility Owner) I certify that a change of ownership of the facility for the subject permit has been issued will occur as indicated in the application. As a condition of the transfer, I do hereby declare that: The transferee will be the owner of the existing treatment facility from which wastewater is discharged, deposited or disposed or the facilities required to comply with the permit will be constructed as described in the application considered by the TCEQ prior to the issuance of the permit. The transferee possesses a copy of the permit, understands the terms and conditions therein, and does accept and assume all obligations of the permit. The transferee assumes financial responsibility for the proper maintenance and operation of all waste treatment and disposal facilities required by the permit or which may be required to comply with the permit terms and conditions. The transferee certifies that the transfer is not made for the purpose of avoiding liability for improper actions carried out prior to the date of transfer. Neither is the transfer made for the purpose of transferring responsibility for improper operations to an insolvent entity. The transferee certifies under penalty of law that this document 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 known violations and revocation of this permit. New Facility Owner: Todd Parton Title: City Man fammn Signature: Date: TAm 2� SUBSCRIBED AND SWORN to before me by the said Pon this day ofJu k 20 My commission expires on the so VA day of )"'da . 20 02-9 `` \``��uu►uur r U''••�1) -IfG�p Of 1304Z�``\\�`. County, Texas TCEQ -20031 (10/=017) Application to Transfer Wastewater Permit or CAFa Permit Page 9 TCEQ Use Only a� ��'kFHTA�nJ TCEQ Core Data Form For detailed instructions on completing 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.) ❑ 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) 0 Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers! n CN 600646012 Central Registry • RN ION22592 SECTION II: Customer Information 4. General Customer Information 5. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change in Legal Name (Verifiable with the Texas Secretary of State or Texas Comptroler of Pub' ic 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 nome first, eg: Doe, John) if new Customer, enter Previous Customer below: City of Leander 7. TX SOS/CPA Filing Number S. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ® 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 Regulated Entitylisted on this form. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant El Other: 1S. Mailing Address: 201 N. Brushy Street City Leander State TX ZIP 78641 ZIP + 4 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if applicable) N/A iturner@leandertx.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 I 1 512 ) 528-2929 I 11 j I SECTION III: Regulated Entity Information 21. General Regulated Entity Information (if 'New Regulated Entity" Is selected, o new permit application is also required.) ❑ 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 Core Data Standards (removal of organizational endings such as Inc, LP, or LLQ. 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional West Wastewaster Treatment Facility 23. Street Address of the Regulated Entity: (No PO Boxes) 1116 East Austin Avenue City Round Rock State Tx ZIP 78664 ZIP + 4 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical location: 26. Nearest City State Nearest ZIP Code Latitude/Longitude ore required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 28. Longitude (W) In Decimal: Degrees Minutes Seconds Degrees Minutes Seconds 30 30 5o 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAIC5 Code 32. Secondary NAILS Code (4 digits) (4 digits) (5 or 6 digits) 15 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NA1CS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City I Round Rock State Tx ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane*roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) (512) 218.3236 (512) 219-5563 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. TCEQ-10400 (11122) Page 2 of 3 Dam Safety 0 D'stricts Edwards Aquifer 0 Emissions Inventory Air 0 Industrial Hazardous Waste ❑ Municipal Solid Waste New Source Review Air ❑ OSSF ❑ Petrpleum Storage Tank ❑ Pw5 Sludge 0 Storm Water Title V Air Tares Used Oi: Voluntary Cleanup 0 Wastewater 0 Wastewater Agriculture U Water Rights Other: WQ0010264001 P1 A" 0 a hk"JILWn r I Z I a I t' tt 41,11 40. Name: ienrn Griesel =TMe-Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-MaH Address ( 512 ) 687.2193 ( j jgrieset@plummer.com SECTION V: Authorized Signature 46. By my signature below. I certify, to the hest of my knowledge, that the information provided in th, s form is true and complete, and that I have signature authority to submit this form on behalf of the entity specified in Section ,I, Field 6 and/or as requ.red for the updates to the ID numbers Idennhed in field 39 comp"r City of Leander lob Title: City Manager Name fin Point) Todd Parton Phone: (5121528. 2929 Signature: Date: I TC1120-1WG0 (111221 Pape 3 of 3 XEG TEXAS COMMISSION ON ENVIRONMENTAL QUALITY APPLICATION TO TRANSFER A WASTEWATER PERMIT OR CAFO PERMIT If you have questions about completing this form please contact the Applications Review and Processing Team at 512-e39-4671. SECTION 1. CURRENT PERMIT INFORMATION What is the Permit Number? WQ0010264o02 What is the EPA I.D. Number? TX 0101940 What is the Current Name on the Permit? Brushy Creek Regional East Wastewater Treatment Plant What is the Customer Number (CN) for the current permittee? CN60043181. CN600135198. and CN6004o7951 What is the Regulated Entity Reference Number (RN): RN 1oo822600 For Publicly Owned Treatment Works (POTWs) Only: a) Does this permit require implementation of an approved pretreatment program by the POTW? Yes ® No ❑ b) Does this permit have a domestic reclaimed water authorization associated with it? NOTE: The domestic reclaimed water authorization associated with this permit will be cancelled on the same date the transfer took place. See instructions for more information. Yes ® No ❑ SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION A. What is the Legal Name of the facility owner? City of Round Rock B. What is the Customer Number (CN) issued to this entity? CN 6o0413181 C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. TCEQ -20031 (10/2012017) Pays i Application to Transfer Wastewater Permit or CAFO Permit SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION D. What is the Legal Name of the facility owner? City of Austin E. What is the Customer Number (CN) issued to this entity? CN 6001'151A8 F. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 2. FACILITY OWNER (APPLICANT) INFORMATION G. What is the Legal Name of the facility owner? City of Cedar Park H. What is the Customer Number (CN) issued to this entity? CN 6004wo5i I. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 3. CO -APPLICANT INFORMATION Complete this section only if another person or entity is required to apply as a co-permittee. A. What is the Legal Name of the co -applicant applying for this permit? WA B. What is the Customer Number (CN) issued to this entity? CN N A C. Complete and attach a Core Data Form (TCEQ-10400) for this customer. SECTION 4. APPLICATION CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed about this application. Application Contact First and Last Name: Ashley Lewis Title: Water Qualityf Permitting Team_ Leader Credentials: N A Company Name: Plummer Associates, Inc. Mailing Address: 8411 N Capital of Texas His,,,Bldg i — Ste 1250 City, State, and Zip Code: Austin Texas 787sq Phone Number: 512-6877:2154 Fax Number: N A E-mail Address: alewis@plummer.com TCEQ -20031 (10/2012017) Page 2 Application to Transfer Wastewater Permit or CAFO Permit SECTION 5. PERMIT CONTACT INFORMATION This is the person TCEQ will contact if additional information is needed during the term of the permit. Permit Contact First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: City of Round Rock Mailing Address: 3400 Sunrise Rd City, State, and Zip Code: Round Rock. TX 7866� Phone Number: 512-218-3236 Fax Number: N A E-mail Address: mthaneProundrocktexas.gov SECTION 6. SITE INFORMATION Site Name: Brushy Creek Regional East Wastewater Treatment Plant SECTION 7. LEASE AND EASEMENT REQUIREMENTS A. Landowner where the facility is or will be located: Landowner Name: City of Round Rock If this individual is not the same person as the facility owner or co -applicant, attach one of the following documents: • A lease agreement or deed recorded easement, if the facility is NOT a fixture of the land, or • A deed recorded easement if the facility IS a fixture of the land. B. Landowner of the effluent disposal site: Landowner Name: NLA If this individual is not the same person as the facility owner or co -applicant, attach a lease agreement. C. For CAFOs: Attach the following records: • Warranty Deed or Property Tax Records • Lease Agreement (for land management units that are not owned by the facility owner or co -applicant) Facility Size on the proof of ownership, in acres: NNA TCEQ -20031 (10/2012017) Page 3 Application to Transfer Wastewater Permit or CAFO Permit SECTION 8. TRANSFER DATE What is the date that the transfer of operator or ownership will occur? 11/1212024 SECTION 9. REPORTING AND BILLING INFORMATION A. Please identify the individual for receiving the reporting forms. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Credentials: P.E. Company Name: City of Round Rock Mailing Address: g400 Sunrise Rd City, State, and Zip Code: Round Rock, TX 7866-r; Phone Number: 512-218-'M6 Fax Number: NNA E-mail Address: mithaneoroundrocktexas.gov B. Please identify the individual for receiving the annual fee invoices. First and Last Name: Michael Thane Title: Director — Utilities and Environmental Services Company Name: City of Round Rock Mailing Address: uoo Sunrise Rd City, State, and Zip Code: Round Rock, TX 7866� Phone Number: S12-218-32.'g6 Fax Number: N A E-mail Address: mthaneRroundrocktexas.gov SECTION 10. DELINQUENT FEES OR PENALTIES Do you owe fees to the TCEQ? Yes ❑ No Do you owe any penalties to the TCEQ? Yes ❑ No Credentials: P.E. If you answered yes to either of the above questions, provide the amount owed, the type of fee or penalty, and an identifying number. NA TCEQ -20031 (10120/2017) Page 4 Application to Transfer Wastewater Permit or CAFO Permit TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Laurie Hadley Title: City Manager, City of Round Rock Sig nature'�6�'OPate: a3/� SUBSCRIBED AND SWORN to before me by the saidZ&(1gL&gW—&on this � � day of IzLa , 20 My commission expires on the day of 20� (Seal) ;''"i' MONIQUEADAMs My Notary ID # 126257913 Expires March 22, 2026 Notary' Public AM.I County, Texas TCEQ -20031 (10/20/2017) Application to Transfer Wastewater Permit or CAFO Permit Page 5 TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing 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.) ❑ New Permit, Registration or Authorization (Core Data Form should be submitted with the program application.) L] Renewal (Core Data Form should be submitted with the renewal form) Ill Other Change in Ownership 2. Customer Reference Number (if issued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers in CN 600413182 Central Reg isW * RN 100822600 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer information ® Change in Regulated Entity Ownership []Change in Legal Name (Verifiable with the Texas Secretary of State or Texas ComptrolBer of Pub?ic 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 lost name first: eg: Doe, John) If new Customer, enter previous Customer below: City of Round Rock 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ individual Partnership: ❑ General ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 0501 and higher 13. Independently Owned and Operated? ❑ Yes ® No 14. Customer Role (Proposed or Actual) — as it relates to the Regulated Entity listed cn th,s f)rm Please check one of the following []Owner ❑ Operator ® Owner & Operator ❑ Other: ❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant 25. Mailing Address: 212 East Main Street City Round Rock State I TX ZIP IfffA ZIP + 4 5245 16. Country Mailing information (if outside u5A) 17. E-Mail Address (if applicable) Ihadley@roundrocktexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (if applicable) TCEQ-10400 (11122) Page 1 of 3 ( 512 ) 218-5410 I 1 ( 512 1 218-7097 SECTION III: Regulated Entity Information 21. General Regulated Entity Information (if 'New Regulated Entity" is selected, a new permit application Is also required.) ❑ 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 Core 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 Regional East Wastewaster Treatment Facility 23. Street Address of the Regulated Entity: 3939 East Palm Valley Boulevard (No PO Boxes) City Round Rock State TX ZIP 78665 ZIP + 4 9443 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78665 Latitude/Longitude are required and may be added/updated to meet TCEQ Care Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 30.526583 28. Longitude (W) In Decimal: 97.620733 Degrees Minutes Seconds Degrees Minutes Seconds 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAILS Code (4 digits) (4 digits) (5 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAILS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City Round Rock State TX ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512 12183236 ( 512) 218-5563 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. TCEQ-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer Emissions Inventory Air ❑ Industrial Hazardous Waste ❑ Municipal Solid Waste ❑ New Source Review Air ❑ OSSF ❑ Petroleum Storage Tank ❑ PWS Sludge 11 Storm Water Title V Air Tires Used Oil ❑ Voluntary Cleanup ® Wastewater ❑ Wastewater Agriculture ❑ Water Rights ❑ Other: WQ0010264002 SECTION IV: PreaarerInformation 40. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address (512) 687-2193 { ) igriesel@plummer.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 required for the updates to the ID numbers identified in field 39. Company: City of Round Rock lob Title: City Manager Name (in Print): Laurie Hadley Phone: Date: (512) 218- 5410 Signature: M TCEQ-10400 (11122) Page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Shay Ralls Roalson Title: Director of Austin Water. City of Austin Signature: Date:l SUBSCRIBED AND SWORN to before me by the said S!)N Rohs R46 _on this 315f day of —) wt, —, 20 My commission expires on the 2 1St day of —)IA.JIe , 20 2S a DEBORAH L OCKLETREEVC04_No ID I Expi7My t: Expirrs June 21, 2025 TCEQ .20031 00/20/2017) Application to Transfer Wastewater Perm 1 or CAFO Permit 1�b'O'A C'�;to' kdA4=nr Notary Public Page 6 orn M,�R, � Z a T i q�MMEH1At O`1*: TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing this form, please read the Core Data Form Instructions or call S12 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 applkation.) U Renewal (Core Data Form should be submitted with the renewal form) ® Other Change in Ownership 2. Customer Reference Number (if issued) Follow. this link to, �carch 3. Regulated Entity Reference Number (ifissued) for CN or RN numbers in CN 60013S198 C@n"Bl R%islry" RN 1008226M SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates Imm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership ❑Change in Legal Name {Verifiable with the Texas Secretary of State or Texas Comptrol er of Publi( 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 11f an individual, print last name first. eg: Doe, John) If new Customer, enter previous Customer below: City of Cedar Park 7. TX SOS/CPA Filing Number S. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Individual Frartnership: ❑ renerai ❑ Lim,t.?d Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Cat-er_ 12. Number of Employees ❑ 0.20 ❑ 21.100 ❑ 101-250 ❑ 251-5D0 ®501 and higher 23. 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 fofbiv ng ®Owner ❑ Operator ❑ Owner & Operator ❑Occupational Licensee ❑ Responsible Party [_1VCP/8SA Applicant El Other: 15. Mailing Address: 625 East loth Street Suite 800 City Austin State TX TIP 1 78701 ZIP + 4 2612 16. Country Mailing Information (if outside USA) 27. E-Mail Address (if oppiicable) robert.goode@austinteKas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number Of applicable) TCEQ-10400 (11122) Page 1 of 3 ( 512 ) 972-0108 ( 911 ) 972-0111 SECTION III: Regulated i Information 21. General Regulated Entity Information (if New Regulated Entity" is selected, a new permit application is olso required) ❑ 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 Core Data Standards (removal of organizational endings such as Inc, LP, or LLQ. 22. Regulated Entity Name (Enter name of the site where the regulated action is taking place.) Brushy Creek Regional East Wastewaster Treatment Facility 23. Street Address of 3939 East Palm Valley Boulevard the Regulated Entity: (No PO Boxed City Round Rock State Tx ZIP 78665 ZIP + 4 4443 24. County Williamson If no Street Address is provided, fields 25-29 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78665 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 30.526583 28. Longitude (W) In Decimal: 97.620733 Degrees Minutes Seconds Degrees Minutes Seconds 29. Primary SIC Code 30.5econdary SIC Code 31. Primary NAICS Code 32. Secondary NAILS Code 4 digits) 4 digits) (5 or 6 digits) 5 or 6 digits) { 8 ) ( i3 } ( 6 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing 340o Sunrise Road Address: City Round Rock State TX ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) 1 512 ) 218-3236 (512) 218-SS63 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. TCEQ-10400 (11I22) Page 2 of 3 Dam Safety Cl Districts Edwards Aquifer Emissions Inventory Air ndustrial Hazardous Waste © Mum4 pal Solid Waste New source Review Air OSSF ❑ Petroleum Storage Tank ❑ PWS Sludge Storm Water Title V Air 0 T-res Used Oil Voluntary Cleanup ® Wastewater ❑ Wastewater Agnculture Water Rights other WQ00102CA002 SECTION IV: Preoarer Information M. Name: tenni Griesel 41. Thle: Project Eng veer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Majl Address T [ 512 l 687.2193 ( 1 jgriesel@plummer-tom SECTION V_:_ Authorized Signature 46. By rm signature below, I certify, to the best of my knowledge, that the information provided in this form -s true and complete, and that I have signature authority to submit this form on behalf of the entity specified n Section I, Field 6 and/or as required for the updates to the 10 numbers identified in field 39. Company: City of Austin Name fin Print): Shay Rails Roalson I Signature: „ _ r Job Title: Director of Austin Water Phone: Date: 1512 j 972- 0108 VZOZY TCEO-10400 (11122y Page 3 of 3 TRANSFEROR SIGNATURE (Current Facility Owner) I consent to the transfer of the permit and 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 3o Texas Administrative Code Section 305.44 to sign this document and can provide documentation in proof of such authorization upon request. Facility Owner Name: Brenda Eivens Title: City Manager,_City of Cedar Park Signature: Date: SUBSCRIBED AND SWORN to before me by the said this day of , 20 on My commission expires on the day of , 20� (Seal) Notary Public TCEQ -20031 (1012012017) Page 7 Application to Transfer Wastewater Permit or CAFO Permit TCEQ Use Only TCEQ Core Data Form For detailed instructions on completing this form, please read the Core Data Form Instructions or call 512-239-5175. SECTION I: General Information 1. Reason for Submission (!f other is checked please describe in space provided.) ❑ New Permit, Registration or Authorization (Core Dato Form should be submitted with the program application.) 0 Renewal (Core Data Form should be submitted with the renewal form) ® Other Change in Ownership 2. Customer Reference Number (ifissued) Follow this link to search 3. Regulated Entity Reference Number (if issued) for CN or RN numbers in CN 600407952 Central Registry" RN 100822600 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change 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 on individual, print lost name first: eg: Doe, John) If new Customer, enter previous Customer below: City of Cedar Park 7. TX SOS/CPA Filing Number S. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ corporation ❑ individual Partnership: ❑Gerrrral ❑ Limited Government: ® City ❑ County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other; 12. Number of Employees ❑ 0.20 ❑21-100 ❑ 101-250 ®251-500 ❑ 501andhigher T3, 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 R Operator [:]Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant El Other: 25. Mailing Address: 450 Cypress Creek Road Bldg 1 City Cedar Park State I TX ZIP 78613 ZIP-4 I �GW 16. Country Mailing Information (if outside USA) 17. E-Mail Address (if appficable) brenda.eivens@cedarparktexas.gov 18. Telephone Number 19. Extension or Code 20. Fax Number elf applicable; TCEQ-10400 (11122) Page 1 of 3 ( 512 )401-5010 I I ( 512 , 250-8602 I SECTION III: Regulated Entity Information 21. General Regulated Entity Information (if 'New Regulated Entity' is selected, anew permit application is also required.) ❑ 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 Core 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 Regional East Wastewaster Treatment Facility 23. Street Address of 3939 East Palm Valley Boulevard the Regulated Entity: (No PO Boxes) City Round Rack State TX ZIP 78665 ZIP + q 9443 24. County Williamson If no Street Address is provided, fields 25-29 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 78665 Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocoding of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 30.526583 28. longitude (W) In Decimal: 97.620733 Degrees Minutes Seconds Degrees Minutes Seconds 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAICS Code 32. Secondary NAILS Code (4 digits) (4 digits) 15 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAILS description.) Treatment of domestic wastewater 34. Mailing Address: 3400 Sunrise Road City I Round Rock State Tx ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexas.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512 ) 218-3236 (S32 ) 218-5563 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. TCEO-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer Emissions Inventory Air Industrial Hazardous Waste ❑ Municipal Solid Waste New Source Review Air ❑ OSSf ❑ Petroleum Storage Tank ❑ PWS Sludge Storm Water Title V Air Tires ❑ Used Oil ❑ Voluntary Cleanup Wastewater Wastewater Agriculture Water Rights ❑ Other: WQ0010264002 SECTION IV: Preuarer Information Q. Name: Jenni Griesel 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address (5121687.2193 ( ) jgriesel@plummer.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 required for the updates to the ID numbers identified in field 39. Company: City of Cedar Park Job Title: City Manager Name (in Print): Brenda Eivens Phone: (512) 401- 5010 Signature: Date: TCEQ-10400 (11122) Page 3 of 3 TRANSFEREE SIGNATURE (New Facility Owner) I certify that a change of ownership of the facility for the subject permit has been issued will occur as indicated in the application. As a condition of the transfer, I do hereby declare that: The transferee will be the owner of the existing treatment facility from which wastewater is discharged, deposited or disposed or the facilities required to comply with the permit will be constructed as described in the application considered by the TCEQ prior to the issuance of the permit. The transferee possesses a copy of the permit, understands the terms and conditions therein, and does accept and assume all obligations of the permit. The transferee assumes financial responsibility for the proper maintenance and operation of all waste treatment and disposal facilities required by the permit or which may be required to comply with the permit terms and conditions. The transferee certifies that the transfer is not made for the purpose of avoiding liability for improper actions carried out prior to the date of transfer. Neither is the transfer made for the purpose of transferring responsibility for improper operations to an insolvent entity. The transferee certifies under penalty of law that this document 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 known violations and revocation of this permit. New Facility Owner: Todd Parton Title: City Mana er i Signature: Date:_ SUBSCRIBED AND SWORN to before me by the said .��t &I., on this 3 Di* day of , 20 My commission expires on the 30q day of 20 JI)K. County, Texas TCEQ -20031 (101204017) Page 0 Application to Transfer Wastewater Penut or CAFO permit 7CEQ Use Only TCEQ Core Data Form For detailed instructions on completing this form, please read the Core Data Form Instructions or call 512-239-5175. SECTION is 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) ® Other Change in Ownership 2. Customer Reference Number (ifissued) Follow this link to sea-ch 3. Regulated Entity Reference Number (ifissued) for CN or RN numbe,s it CN 600646012 Central Registry* * RN 100822600 SECTION II: Customer Information 4. General Customer Information S. Effective Date for Customer Information Updates (mm/dd/yyyy) 11/12/2024 ❑ New Customer ❑ Update to Customer Information ® Change in Regulated Entity Ownership ❑Change 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 on individual, print fast name first: eg: Doe, John) 11 new Customer, enter previous Customer below: City of Leander 7. TX SOS/CPA Filing Number 8. TX State Tax ID (11 digits) 9. Federal Tax ID (9 digits) 10. DUNS Number (if applicable) 11. Type of Customer: ❑ Corporation ❑ Indlviduat Partnership: ❑ General ❑ . imited Government: ® City [] County ❑ Federal ❑ Local ❑ State ❑ Other ❑ Sole Proprietorship ❑ Other: 12. Number of Employees ❑ 0-20 ❑ 11-100 ®101-250 ❑ 251-500 ❑ 501and higher 13. Independently Owned and Operated? ❑ Yes ® No 14. Customer Role (Proposed or Actual) — as it relates to the Regulated Entity listed on this farm. Please check one of the following ®Owner ❑ Operator ❑ Owner & Operator ❑Occupational Licensee [I Responsible Party ❑ VCP/BSA Applicant ❑Other: 1S. Mailing Address: 201 N. Brushy Street City Teander State TX ZIP 7$641 ZIP + p 16. Country Mailing Information (if autswe USA) 17. E-Mail Address (if applicable) N/A iturner@leandertx.gov 18. Telephone Number 19. Extension or Code 20. Fax Number (of applicable) TCEa-10400 (11122) Page 1 of 3 ( 512 ) 528-2929 - _ I I ( } SECTION III: Reaulated Entity InformatigI3 21. General Regulated Entity Information (if New Regulated Entity" is selected, a new permit application is also required.) ❑ 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 Core 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 Regional East Wastewaster Treatment Facility 23. Street Address of 3939 East Palm Valley Boulevard the Regulated Entity: (No PO Boxes) City Round Rock State TX ZIP 78665 ZIP + 4 9443 24. County Williamson If no Street Address is provided, fields 25-28 are required. 25. Description to Physical Location: 26. Nearest City State Nearest ZIP Code Round Rock TX 7866S Latitude/Longitude are required and may be added/updated to meet TCEQ Core Data Standards. (Geocading of the Physical Address may be used to supply coordinates where none have been provided or to gain accuracy). 27. Latitude (N) In Decimal: 30.526583 29. Longitude (W) In Decimal: 97.620733 Degrees Minutes Seconds Degrees Minutes Seconds 30 30 50 97 40 0 29. Primary SIC Code 30. Secondary SIC Code 31. Primary NAILS Code 32. Secondary NAICS Code (4 digits) (4 digits) (5 or 6 digits) (5 or 6 digits) 4952 221320 33. What is the Primary Business of this entity? (Do not repeat the SIC or NAICS description.) Treatment of domestic wastewater 34. Mailing 3400 Sunrise Road Address: City Round Rock State TX ZIP 78665 ZIP + 4 2398 35. E-Mail Address: mthane@roundrocktexes.gov 36. Telephone Number 37. Extension or Code 38. Fax Number (if applicable) ( 512) 219-3236 ( 512 ) 219-SS63 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. Seethe Core Data Form instructions for additional guidance. TCEQ-10400 (11122) Page 2 of 3 Dam Safety Districts Edwards Aquifer Em:sslons Inventory Air LJ Industrial Hazardous Waste —ff Municipal Solid Waste New Source Review Air OSSF ❑Petroleum Storage Tank ❑ PWS LJ Sludge Storm Water Title V Air Tires used oil Voluntary Cleanup Wastewater Wastewater Agriculture Water Rights U other: WCt00102"W2 40. Name: Jenni Griesef 41. Title: Project Engineer 42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address l 512 j 687.2293 [ j jgdesel@plumnwcom SECTION V,, Authoriged Signature ". By my signature below, I certify, to the best of my knowledge, that the Information provided in thy$ form is true and complete, and that I have signature authority to submit this form on behalf of the entity specified in Section ll, Field 6 and/or as required for the updates to the ID numbers identified in field 19. Company: City of Leander Job Title: Name (in Print). Todd Parton Signature: - � , City Manager 77 hone: {512 } 52E 2929 Date: 7/1 TCEQ-10400 (11 f22? Pago 3 of S