CM-2024-218 - 8/23/2024MEMO
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 00102b 002
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? CN6o0413181, CN600insio&
and CN6owmos1
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 60041ei181
C. Complete and attach a Core Data Form (TCEQ-10400) for this customer.
�ln-- 49t -ale
TCEQ -20031 (1(120/2017)
Application to Transfer Wastewater Permit or CAFO Permit
Pa9p 1
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 600igg1A8
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?
NA
B. What is the Customer Number (CN) issued to this entity? CN NNA
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: 8911 N Capital of Texas Hwy, Bldg 1— Ste 1250
City, State, and Zip Code: Austin, Texas 787s9
Phone Number: 512-687-2154 Fax Number: NNA
E-mail Address: alewisPplummer.com
TCEQ -20031 (10/20/2017) 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: 3400 Sunrise Rd
City, State, and Zip Code: Round Rock, TX 7866.r;
Phone Number: 512-218-3256 Fax Number: NNA
E-mail Address: mthane@roundrocktexas.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: N A
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 7866.r,
Phone Number: ,512-218-'A2g6 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: uoo Sunrise Rd
City, State, and Zip Code: Round Rock, TX 78665
Phone Number: S12-218-'12g6 Fax Number: NLA
E-mail Address: mthane(@roundrocktexas.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 (10/20/2017) 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
Signature: Date:
- - - I 1 (9— 4 2W
SUBSCRIBED AND SWORN to before me by the said4�'Uon
this P 3�" day of ' - o
My commission expires on the �� day of
(Seal)
MONIQUEADAM5
.� :•= My Notary SD # 126257913
Expires March 22, 2026
TCEa -20031 (1012012017)
Application to Transfer Wastewater Permit or CAFO Permit
ary Public
l �C�►.--
County, Texas
Page 5
TCEQ Use Only
TCEQ Core Data Form
For detailed instructions on completing this form, please read the tore 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 Oato Form should be submitted with the renewal form) Lg 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 nu -ethers in
CN 600413181 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 (lf 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-SOD ®501 and higher
ndently Owned and Operated?
®No
FE
14. Customer Role (Proposed or Actual) — as it relates to the Regulated Entity listed on this form. Please check one of the following
❑Owner ❑ Operator ® Owner & Operator
❑Occupational Licensee ❑ Responsible Party ❑ VCP/SSA Applicant ❑Other:
15. Mailing
212 East Main Street
Address:
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
5245
16. Country Mailing Information (if outside USA)
17. E-Mail Address (if applicable)
Ihadley@ round rocktexa s.gov
18. Telephone Number
19. Extension or Code
20. Fax Number (if oppikable)
TCEQ-10400 (11122) Page 1 of 3
1512 ] 218-5410 I I ( 512 1219-7097 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 Care Data Standards (removal of organizational endings such
as Inc, LP, or LLC).
22. Regulated Entity Name (Enter name of the site where the regulated octlon is taking place.)
Brushy Creek Regional East Wastewaster Treatment Facility
23. Street Address of
3939 East Palm Valley Boulevard
the Regulated Entity:
1No PQ 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 Core Data Standards. (Geocoding of the Physical Address may be
used to supply coordinates when: 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 32. 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 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
(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 (11122) Page 2 of 3
Dam Safety
Districts
0 Edwards Aquifer
0 Emissions Inventory Air
0 Industrial Hazardous Waste
❑ Municipal Solid Waste
❑ New SourceReview Air
❑ OSSF
❑Petroleum Storage Tank
❑ PWS
Sludge
❑ Storm Water
Title V Air
Tres
Used Oil
❑ Voluntary Cleanup
® wastewater
❑ Wastewater Agriculture
❑ Water Rights
❑ Other
WQ0010264Do2
SECTION IV: Preoarer Information
40. Name: Jenni Griesei 41. Title: Project Engineer
42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mail Address
1512 j 687-2193 ( } jgriesel@plummer.com
SECTION V: Authorized i n r
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 n Section II, Field 6 and/or as required for the updates to the ID numbers identified infield 39.
Company:
City of Round Rock
Job Title: City Manager
Name (in Print):
Laurie Hadley
Phone:
1512 ) 218- 5410
Signature:
// / � � t e ,
Date:
A
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: &o LAI=" . Date: [ [ 91'Z
SUBSCRIBED AND SWORN to before me by the said Sirq Uls gootm on
this_ 31St - day of �_ ,--, 20 z�
My commission expires on the ZIS} day of_Me , 20 2S
DEBORAHLOCKLETREE
n Not ti 173787
+„ Ay C i 1
Expires
a d4' June 21, 2025
TCEQ -20031 (1012012017)
Application to Transfer Wastewater Permil or CAFO Permit
jlbotcjA or kald==r
Notary Public
Page A
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 (Care Data Form should be submitted with the renewal form) ® Other Change in Ownership
2. Customer Reference Number (if issued) f2LIgw hiA IinkSy 3. Regulated Entity Reference Number (ifissued)
for CN or RN numbers in
CN 600135198 Lentral.RtogrC 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 (!fan 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
8. TX State Tax ID (11 digits)
9. Federal Tax 10
(9 digits)
10. DUNS Number (if
applicable)
21. 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
[]Occupational Licensee ❑ Responsible Party ElVCP/BSA Applicant ❑Other:
15. Mailing
625 East 10th Street
Address:
Suite B00
City
Austin
State
TX
ZIP 78701
ZIP + 4
2612
16. Country Mailing Information (if outside USA)
17. E-Mail Address (if applicable)
robert.goode@austintexas.gov
18. Telephone Number
19. Extension or Code 20. Fax Number (if applicable)
TCEQ-10400 (11122) Page 1 of 3
( 512 ) 972-0108
SECTION III: Regulated Entity Information
( 512 ) 972.0111
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 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 l
city Round Rock
State
TX
ZIP
7$665
ZIP + 4
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 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 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 39. Fax Number (if applicable)
(512) 2183236
1512 ) 218-5S63
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 this
form. See the Core Data Form instructions for additional guidance.
TCEQ-10400 (11/22) Page 2 of 3
Dam Safety
0 Districts
Edwards Aquifer
Lj Emissions Inventory Air
industrial Hazardous Waste
❑ Munit pal Solid Waste
New SourceReview Air
❑ OSSf
❑Petroleum Storage Tank
❑ PW5
Sludge
Storm water
Lj Title V Air
0 Tres
0 Used Oil
Voluntary Cleanup
® Wastewater
❑ wastewater Agr,cullure
C1 Water Rights
0 Other:
WQ0010264002
SECTION IV: Pre2arer information
40. Name: Jenni Griesel 41. Title: Project Eng neer
42. Telephone Number 43. Ext./Code 44. Fax Number 45. E-Mag Address
( 512 ) U7.2193 I j 16rieselt4Dplummer.com
SECTION Ve Authorized Signature
46• By my 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 requ red for the updates to the ID numbers identified in held 39
Company: City of Austin Job Title: Director of Austin Water
Name (to Print): Shay Rails Roalson Phone: [ $12 ► 972 0108
Signature: Date:
E-
TCED-10400 (11122j 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�
My commission expires on the day of , 20
(Seal)
TCEQ -20031 (10/20/2017)
Application to Transfer Wastewater Permit or CAFO Permit
Notary Public
Page T
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 (ff 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 (lf issued) Follow this link to search 3. Regulated Entity Reference Number (lfissued)
for CN or RN numbers in
CN 600407951 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 Stare
(SOS) or Texas Comptroller of Public Accounts (CPA).
6. Customer Legal Name (lf an individual, print last name first: eg: Doe, John) jnew 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 8f 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:
❑Occupational Licensee ❑ Responsible Party ❑ VCP/BSA Applicant
15. Mailing
Address:
450 Cypress Creek Road
Bldg 1
City
Cedar Park
State
TX
21P
78613
21P + 4
3(.-.
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 (if applicable)
TCEQ-10400 (11122) Page 1 of 3
( 512 ) 401-5010
SECTION III. Regulated EntltvInformation
( 512 1 250-8602
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 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
the Regulated Entity:
(No PO 8oxesl
3939 East Palm Valley Boulevard
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 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 SlCor 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) 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 tNs
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
0 Storm Water
I Title V 'AirTires
Used Oil
❑ Voluntary Cleanup
® Wastewater
❑ Wastewater Agriculture
❑ Water Rights
❑ Other:
WQ0010264002
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 ( ) jgriesel@plummercom
SECTION V: Authorized Signature
46. By my signature below, I certify, to the best of my knowledge, that the information provided in this form is true and complete, and that I have signature authority
to submit this form on behalf of the entity specified in Section 11, Field 6 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:
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:CRXManaLer i
Signature: Date:_
SUBSCRIBED AND SWORN to before me by the said —• 4n on
this 30 day of , 20 0�
My commission expires on the 3 Dt day of AU 20—A &
��,5eal)
:OE` gam'
CFTE�'P
County, Texas
TCEO-20031(1012012017) Page 9
Application to Transfer wastewater Pem -at 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) Fallow this link to search 3. Regulated Entity Reference Number (if issued)
for CN or RN numbers in
CN 600646012 Central Registry' RN 100822600
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 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 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. j1pe 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 an the farm. please check one of the fomgwing
®Owner ❑ Operator ❑ Owner & Operator
❑ Other:
❑Occupational L censee ❑ Responsible Party ❑ VCP/BSA Appl;:ant
15. Mailing
Address:
201 N. Brushy Street
City Leander
State
Tx
ZIP
7 K41
ZIP + 4
16. Country Mailing Information (if outside USA)
17. E-Mail Address (if applicob!e1
N/A
iturner@leandertx.gov
18. Telephone Number
19. Extension or Code
20. Fax Number (lfapplicable)
TCEQ-10400 (11122) Page 1 of 3
L112 ) 528-2929
SECTION III: Regulated Entity Information
21. General Regulated Entity Information (if 'New Regulated Entity" is selected, a new permit opplkation 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 East Wastewaster Treatment Facility
23. Street Address of
3939 East Palm Valley Boulevard
the Regulated Entity:
LNo 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
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 SfC or NA1CS description.)
Treatment of domestic wastewater
34. Mailing
Address:
34M Sunrise Road
City I Round Rock
State
TX
ZIP
1 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-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 (11122) Page 2 of 3
Dam Safety
Districts
Edwards Aquifer
Emissions inventory Air
LJ Industrial Hazardous Waste
❑ Municipal Solid Waste
New Source
Review Air
❑ OSSF
❑Petroleum Stange Tank
❑PINS
Sludge
U Storm water
U Tires
U Used Oil
Voluntary Cleanup
Wastewater
Wastewater Agriculture
Water Rights
Other
WQDD10264002
81 4 r 1 r IL • 1
40. Name: )enni Griesel 41. Title: Protect Engineer
42. Telephane Number 43. Ext./code 44. Fax Number 4S. E-Mall Address
(512) 687-2193 ( } Tj;;eseIQQpIummer.coM
". 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 to, Field 6 and/or as required for the updates to the ICJ numbers identified in field 39.
Company: city of Leander Job Tides City Manager
Name fin Print): Todd Parton Phone: (512 )S2a 2929
signature: � dot@: ��
TCEa-10400 (11122) Page 3 of 3