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CM-2025-187 - 7/25/2025 ,1tP Gowiviss,O4, TCEQ Use Only " 2 °NMW 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 Re-Use Authorization Amendment 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 100822600 SECTION II: Customer Information 4.General Customer Information 5.Effective Date for Customer Information Updates(mm/dd/yyyy) ❑New Customer ®Update to Customer Information ❑Change in Regulated Entity Ownership ❑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 10.DUNS Number(if applicable) 17460174851 (9 digits) 74-6017485 11.Type of Customer: ❑Corporation ❑Individual Partnership:❑General❑Limited Government:®City❑County❑Federal❑Local ❑State❑Other ❑Sole Proprietorship ❑Other: 12.Number of Employees 13.Independently Owned and Operated? ❑0-20 ❑21-100 ❑101-250 ❑251-500 0 501 and higher ®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 212 E.Main Street 15.Mailing Address: City Round Rock State Tx ZIP 78664 ZIP+4 16.Country Mailing Information(if outside USA) 17.E-Mail Address(if applicable) bbennett@roundrocktexas.gov TCEQ-10400(11/22) OA —2025 — IS 7 Page 1 of 3 18.Telephone Number 19.Extension or Code 20.Fax Number(if applicable) ( 512 )218-5410 ( 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 Inc,LP,or LLC). 22.Regulated Entity Name(Enter name of the site where the regulated action is taking place.) Brushy Creek Wastewater Treatment Facility-East Plant 23.Street Address of 3939 E Palm Valley Blvd the Regulated Entity: (No PO Boxes) City Round Rock State TX ZIP 78665 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: 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 SIC or NAICS description.) The Facility treats domestic wastewater. 3400 Sunrise Road 34.Mailing Address: City Round Rock State TX ZIP 78664 ZIP+4 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 TCEQ-10400(11/22) Page 2 of 3 39.TCEQ Programs and ID Numbers Check all Programs and write in the permits/registration numbers that will be affected by the updates submitted on this form.See the Core Data Form instructions for additional guidance. ❑Dam Safety ❑Districts ❑Edwards Aquifer ❑Emissions Inventory Air ❑Industrial Hazardous Waste ❑New Source ❑Municipal Solid Waste ❑OSSF ❑Petroleum Storage Tank El PWS Review Air O Sludge ❑Storm Water ❑Title V Air ❑Tires 0 Used Oil O Voluntary Cleanup ❑Wastewater El Wastewater Agriculture ❑Water Rights ❑Other: SECTION IV: Preparer Information 40.Name: Adam Levy,P.E. 41.Title: Staff Engineer 42.Telephone Number 43.Ext./Code 44.Fax Number 45.E-Mail Address (512)341-3394 (512)255-6911 alevy@roundrocktexas.gov SECTION V: Authorized Signature 46. By my signature below,I certify,to the best of my knowledge,that the information provided in this form is true and complete,and that I have signature authority to submit this form on behalf of the entity specified in Section 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(In Print): Brooks Bennett Phone: (512)218-7070 Signature: -2)0,)62 .74t Date: 1I I CJ�Z5 TCEQ-10400(11/22) Page 3 of 3 Mayor Councilmembers City Manager Craig Morgan Michelle Ly Brooks Bennett Rene Flores Melissa Fleming ROUND ROCK TEXAS Mayor Pro-Tem Frank Ortega City Attorney Puuuc WoRKs Kristin Stevens Hilda Montgomery Stephanie L. Sandre July 9, 2025 Texas Commission on Environmental Quality Water Quality Division (MC-148) 12100 Park 35 Circle Austin,TX 78753 RE: City of Round Rock Amendment to Reuse Authorization#R-10264002 To Whom It May Concern at the Water Quality Division, Thank you for helping the City of Round Rock (City)conserve its drinking water through Type I Reclaimed Water. As the City has expanded, and water demand in the region increases, we have found increased interest in our reclaimed water. To this end,we wish to expand our service area and allow our customers to use all allowable uses of Type I reclaimed water.This amendment aims to add the authorized uses and expand our reuse service area to match our current Water Certificate of Convenience and Necessity, No. 11047. We have enclosed the updated TCEQ Forms #10400 and #20427, a map of our desired reclaimed water service area, and our current customers' reuse contracts with operation and maintenance plans, as required. Please get in touch with Adam Levy at alevy@roundrocktexas.gov or 512-341-3394 if you have any questions regarding the enclosed documents. Sincerely, /it •c d Michael Thane, P.E., Executive Director City of Round Rock Public Works Enclosures CITY OF ROUND ROCK PUBLIC WORKS DEPARTMENT•3400 Sunr se Road,Round Rock,Texas /8665 (P)5'2.218.5555•(1) 512.255.6916•roundrocktexas.gov TCEQ Office Use Only Permit No: CN: RN: Region: VIAuthorization for Re-Use of Domestic Reclaimed Water � This application is for the beneficial reuse of domestic reclaimed water in accordance with 30 Texas Administrative Code (TAC) Chapter 210,�� Subchapters A, B, C, and D. REASON FOR APPLICATION: Select the reason you are submitting this application: ❑ New authorization © Amendment of reuse authorization number: R 10264002 SOURCE OF THE RECLAIMED WATER: What is the permit number for the wastewater treatment plant where the reclaimed water is produced: WQ00 10264002 What is the expiration date of the wastewater permit? January 1 2029 Section 1. Producer (A I s licant) a) What is the Customer Number (CN) issued to this entity? CN 600413181 b) What is the Legal Name of the entity(applicant) applying for this authorization? (The legal name must be spelled exactly as filed with the Texas Secretary of State, County, or in the legal document forming the entity.) City of Round Rock Section 2. Provider Is the Provider the same as the Producer? ® Yes, go to Section 3) 0 No, complete section below a) What is the Customer Number (CN) issued to this entity? CN b) What is the Legal Name of the entity(applicant) applying for this authorization? (The legal name must be spelled exactly as filed with the Texas Secretary of State, County, or in the legal document forming the entity.) Section 3. Application Contact This is the person TCEQ will contact if additional information is needed about this application. Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Adam Levy Suffix: Title: Staff Engineer Credentials: M.S. P.E. TCEQ-20427(02/2o/2oi7) Page 1 Authorization for Re-Use of Domestic Reclaimed Water Phone Number: (512) 341-3394 Fax Number: 512-255-6911 Email: alevy@roundrocktexas.gov Mailing Address: 3400 Sunrise Road City, State, and Zip Code: Round Rock, Texas 78665 Section 4. Re(julated Entit (RE) Information For this section, provide the requested information for the wastewater treatment plant (WWTP) where the reclaimed water is produced. a) What is the Regulated Entity Number (RN) issued to the WWTP? RN 100822600 b) What is the Site Name for the WWTP? Brushy Creek Wastewater Treatment Facility-East Plant Section 5. General Characteristics a) Type of reclaimed water being used: ® Type I ❑ Type II ❑ Both b) Identify additional treatment processes that may be needed to achieve the effluent quality. Type I: existing polishing filter, existing disinfection Type II: c) Provide the following effluent limits in the WWTP discharge permit. 1. Flow, in million gallons per day: Current: 40 Proposed, if applicable: 2. Oxygen Demand. Select the appropriate limit and provide the limit value. ❑ BODS • CBODS Limit value, in milligrams per liter: 7 3. Bacteria. Select the appropriate limit and provide the limit value. • Escherichia coli ❑ Enterococci Limit value, in colony forming units per 100 milliliters: 126 Section 6. Stora:e Re I uirements a) Is the reclaimed water stored in a fabricated tank that is leak proof certified? ® Yes, go to Section 7 0 No, complete section below b) Are any of the reclaimed water storage or usage sites located in the Edwards Aquifer Recharge Zone? TCEQ-20427(02/20/2017) Page 2 Authorization for Re-Use of Domestic Reclaimed Water Yes ❑ No c) Are any of the reclaimed water usage sites located outside the Edwards Aquifer Recharge Zone, but within the DRASTIC Designated Areas having a pollution potential index figure of 110 or greater? ❑ Yes ❑ No d) If you answered Yes to questions b) or c), complete the following questions. 1. Do pond construction materials meet 30 TAC §210.23(c)(1), (2), and(4)? • Yes ❑ No ❑ NA 2. Do liners meet the requirements in 30 TAC §210.23(c)(3) or (5)? ❑ Yes ❑ No ❑ NA 3. Have the liners been certified according to 30 §TAC 210.23(c)(6)? ❑ Yes ❑ No ❑ NA 4. Do the soil embankment walls meet the requirements in 30 TAC §210.23(c)(7)? ❑ Yes ❑ No ❑ NA 5. If you answered No or NA to questions 1) - 4), provide an explanation. No holding ponds exist. No holding ponds are planned or proposed. e) If you answered No to questions b) and c), complete the following questions. 1. Do pond construction materials meet 30 TAC §210.23(d)(1) and (2)? ❑ Yes ❑ No ❑ NA 2. Do liners meet the requirements in 30 TAC §210.23(d)(3) or (4)? ❑ Yes ❑ No ❑ NA 3. Have the liners been certified according to 30 §TAC 210.23(d)(5)? ❑ Yes ❑ No ❑ NA 4. Do the soil embankment walls meet the requirements in 30 TAC §210.23(d)(6)? ❑ Yes ❑ No ❑ NA 5. If you answered No or NA to questions 1) - 4), provide an explanation. Section 7. Reclaimed Water Uses a) Describe all potential uses of the reclaimed water at the WWTP. Wash down water, chemical carrier water, general process water &wash water for equipment, construction water (compaction, dust suppression). b) Describe all potential uses of the reclaimed water at other sites. Cooling tower makeup water, dust suppression, soil compaction, residential and TCEQ-20427(02/2o/2o17) Page 3 Authorization for Re-Use of Domestic Reclaimed Water urban irrigation, fire protection, agricultural irrigation, maintenance of impoundments. and toilet and urinal flushing. Section 8. Reclaimed Water Users a) Is the producer, provider, and user the same entity? 0 Yes, go to Section 9 181 No, attach a copy of the contract template and complete this section. b) Does the contract have an operation and maintenance plan as required by 30 TAC 210.4(a)(4)? IS Yes, attach a copy of the operation and maintenance plan. 0 No. Do not submit this form until an operation and maintenance plan has been developed. c) For each user, provide the following information. If there are more than two users, complete Attachment A. 1. Name of the User: 2. What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Suffix: Title: Credentials: Phone Number: Fax Number: Email: Mailing Address: City, State, and Zip Code: 3. Types of Uses (irrigation, dust suppression, cooling water, etc): 4. Is there a contract, legal agreement, or ordinance between this user and the provider? ❑ Yes ❑ No If no, please explain: S. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ❑ Yes ❑ No If no, please explain: 1. Name of the User: 2. What is the contact information for this User? TCEQ-2o427(02/20/2o17) Page 4 Authorization for Re-Use of Domestic Reclaimed Water Prefix(Mr. Ms. or Miss): First and Last Name: Suffix: Title: Credentials: Phone Number: Fax Number: Email: Mailing Address: City, State, and Zip Code: 3. Types of Uses (irrigation, dust suppression, cooling water, etc): 4. Is there a contract, legal agreement, or ordinance between this user and the provider? ❑ Yes ❑ No If no, please explain: 5. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ❑ Yes ❑ No If no, please explain: Section 9. Attachments This application must include the following attachments: a) A completed Core Data Form(TCEQ 10400); b) A map of the service area for the reclaimed water; c) A map showing the location of all reclaimed water storage ponds; d) A copy of the user contracts, if the user is a different entity than the producer and provider; and e) A copy of the operation and maintenance plan for each contract. TCEQ-20427(02/2o/2017) Page 5 Authorization for Re-Use of Domestic Reclaimed Water Section 10. Producer Certification I understand that if there is a major change in the use of reclaimed water, the producer/provider must notify the TCEQ of the change at least 45 days before the planned implementation. Examples of major changes include: • a change in the boundary of the approved service area; • the addition of a new user; • a change in the intended uses; and • a change from Type I to Type II reclaimed water or vice versa. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I further certify that I am authorized under 30 Texas Administrative Code §305.44 to sign and submit this document, and can provide documentation in proof of such authorization upon request. Producer Signatory Name: Brooks Bennett Producer Signatory Title: City Manager Jul/ I Signature(use blue ink): Date: 711515 TCEQ-20427(02/2o/2o17) Page 6 Authorization for Re-Use of Domestic Reclaimed Water Section 11. Provider Certification If the provider is a different entity than the producer, the provider must complete this section. I understand that if there is a major change in the use of reclaimed water, the producer/provider must notify the TCEQ of the change at least 45 days before the planned implementation. Examples of major changes include: • a change in the boundary of the approved service area; • the addition of a new user; • a change in the intended uses; and • a change from Type I to Type II reclaimed water or vice versa. I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I further certify that I am authorized under 30 Texas Administrative Code §305.44 to sign and submit this document, and can provide documentation in proof of such authorization upon request. Provider Signatory Name: Provider Signatory Title: Signature(use blue ink): Date: TCEQ-20427(02/2o/2017) Page 7 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 1. Name of the User: Austin Community College District 2. What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Andy Kim Suffix: Title: Director of Energy&SustainabilityCredentials: CEM, LEED AP Phone Number: 512-223-1123 Fax Number: Email: utility@austincc.edu Mailing Address: 9101 Tuscany Way City, State, and Zip Code: Austin, TX 78754 3. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation, toilet flushing. cooling water 4. Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 5. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/20I7) Page 8 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 6. Name of the User: Avery Centre East HOA 7. What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Kevin Henry_ Suffix: Title: Senior Manager of Developer Services Credentials: CMCA Phone Number: 855-289-6007 Fax Number: Email: kevin.henry@goodintx.com Mailing Address: P.O. Box 4579. Dept. 846 City, State, and Zip Code: Houston. TX 77210 8. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 9. Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 10.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 9 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 11.Name of the User: Avery Centre Master Association. Inc. 12.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Kevin Henry Suffix: Title: Senior Manager of Developer Services Credentials: CMCA Phone Number: 512-852-7943 Fax Number: Email: ACCMmanager@goodwintx.com Mailing Address: P.O. Box 4579. Dept. 846 City, State, and Zip Code: Houston, TX 77210 13.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 14.Is there a contract, legal agreement, or ordinance between this user and the provider? N Yes ❑ No If no, please explain: 15.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes D No If no, please explain: TCEQ-20427(02/20/2o17) Page io Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 16.Name of the User: Avery Centre East Homeowners Association 17.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Kevin Henry Suffix: Title: Senior Manager of Developer Services Credentials: CMCA Phone Number: 512-852-7943 Fax Number: Email: kevin.henry@goodintx.com Mailing Address: P.O. Box 4579. Dept. 846 City, State, and Zip Code: Houston. TX 77210 18.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 19.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 20.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2o17) Page ii Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 21.Name of the User: Azola Avery Owner. LP 22.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Colin McElwrath Suffix: Title: Credentials: Phone Number: 737-302-5583 Fax Number: Email: crm@zomliving.com Mailing Address: 1909 Woodall Rodgers Fwy. Suite 400 City, State, and Zip Code: Dallas, TX 75201 23.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 24.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 25.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 12 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 26.Name of the User: WMCi Austin VII LLC 27.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Ms. First and Last Name: Laura Bodeman Suffix: Title: Credentials: Phone Number: 804-967-5209 Fax Number: Email: utilitybilling@weinsteinproperties.com Mailing Address: 3951 Stillman Parkway City, State, and Zip Code: Glen Allen, VA 23060 28.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 29.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 30.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 13 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 31.Name of the User: NORTHERN IRELAND ENTERPRISES LLC 32.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Jair Garcia Suffix: Title: Credentials: Phone Number: 512-582-0155 Fax Number: Email:jair@corkandbarrelpub.com Mailing Address: 4000 E Palm Valley Blvd City, State, and Zip Code: Round Rock. TX 78665 33.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 34.Is there a contract, legal agreement, or ordinance between this user and the provider? E Yes ❑ No If no, please explain: 35.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? 0 Yes ❑ No If no, please explain: TCEQ-20427(02/20/2o17) Page 14 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 36.Name of the User: Diamond Oaks Condominium Community. Inc. 37.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Associa Hill Country Suffix: Title: Credentials: Phone Number: 512-328-6100 Fax Number: Email: ahc.info@associa.us Mailing Address: PO Box 650853 City, State, and Zip Code: Dallas. TX 75265 38.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 39.Is there a contract, legal agreement, or ordinance between this user and the provider? El Yes ❑ No If no, please explain: 40.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? D Yes O No If no, please explain: TCEQ-20427(02/20/2017) Page 15 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 41.Name of the User: Forest Creek HOA, Inc. 42.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Raynell Martinez Suffix: Title: Credentials: Phone Number: 512-981-9723 Fax Number: Email: forcreek@cirmail.com Mailing Address: P.O. Box 803555 City, State, and Zip Code: Dallas, TX 75301 43.Types of Uses (irrigation, dust suppression, cooling water, etc): 44.Is there a contract, legal agreement, or ordinance between this user and the provider? ❑ Yes ❑ No If no, please explain: 45.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ❑ Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page i6 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 46.Name of the User: Forest Grove Master Community 47.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Tack Stapleton Suffix: Title: Credentials: Phone Number: Fax Number: Email:jack@realtytexas.com Mailing Address: PO Box 909 City, State, and Zip Code: Tualatin, OR 97062 48.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 49.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 50.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/2o/2017) Page 17 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 51.Name of the User: Hat Creek Burger Company 52.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Lucas Lee Suffix: Title: Credentials: Phone Number: 512-428-6164 Fax Number: Email: llee@hatcreekburgers.com Mailing Address: 4407 Bee Cave Rd. Suite 212 City, State, and Zip Code: Austin, TX 78746 53.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 54.Is there a contract, legal agreement, or ordinance between this user and the provider? ►z� Yes ❑ No If no, please explain: 55.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/2o/2017) Page i8 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 56.Name of the User: Heritage at Vizcaya Community Association 57.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Olha Shockey Suffix: Title: Credentials: Phone Number: 737-209-8650 Fax Number: Email: oshockey@ccmcnet.com Mailing Address: 8360 E Via De Ventura L100 City, State, and Zip Code: Scottsdale, AZ 85258 58.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 59.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 60.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 19 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 61.Name of the User: KAL HOSP 1 LLC 62.What is the contact information for this User? Prefix(Mr. Ms. or Miss): Mr. First and Last Name: Rich Bertin Suffix: Title: Credentials: Phone Number: 737-300-6008 Fax Number: Email: rbertin@kalhospitalityllc.com Mailing Address: P.O. Box 590 City, State, and Zip Code: Wisconsin Dells, WI 53965-0590 63.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 64.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 65.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ►� Yes ❑ No If no, please explain: TCEQ-20427(02/2o/2o17) Page 20 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 66.Name of the User: KR Aquisitions 67.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Hugh Schavier Suffix: Title: Credentials: Phone Number: 512-582-3879 Fax Number: Email: HSchavier@kalahriresorts.com Mailing Address: PO Box 590 City, State, and Zip Code: Wisconsin Dells, WI 53965-0590 68.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation, Cooling Water 69.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes El No If no, please explain: 70.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes 0 No If no, please explain: TCEQ-20427(02/20/2o17) Page 21 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 71.Name of the User: Legends Village HOA 72.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Tennifer English Suffix: Title: Credentials: Phone Number: 512-739-7124 Fax Number: Email: Jennifer.english@inframark.com Mailing Address: 13915 N Mopac Expy, Ste. 105 City, State, and Zip Code: Austin, TX 78728 73.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 74.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 75.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 22 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 76.Name of the User: LNR Interests LP/Diamond Oaks II 77.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Karen Tunnell Suffix: Title: Credentials: Phone Number: 512-306-1771 Fax Number: Email: ktunnell@carrdevelopment.com Mailing Address: 5121 Bee Cave Rd. Ste. 207 City, State, and Zip Code: Austin, TX 78746 78.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 79.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 80.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 23 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 81.Name of the User: Meadows at Chandler Creek MUD 82.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Makenzi Scales Suffix: Title: Credentials: Phone Number: 713-594-6335 Fax Number: Email: Makenzi.scales@inframark.com Mailing Address: 98 San Jacinto Boulevard Suite 1900 City, State, and Zip Code: Austin, TX 78701 83.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 84.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 85.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 24 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 86.Name of the User: R Bank 87.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Mark Kesselring Suffix: Title: Credentials: Phone Number: 844-722-6589 Fax Number: Email: MKesselring@r.bank Mailing Address: 3600 E Palm Valley Blvd City, State, and Zip Code: Round Rock, TX 78665 88.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 89.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 90.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2o17) Page 25 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 91.Name of the User: Round Rock Baseball Club LP 92.What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Deborah Coughlin Suffix: Title: Credentials: Phone Number: 512-255-2255 Fax Number: Email: dcoughlin@rrexpress.com Mailing Address: 3400 E Palm Valley Blvd City, State, and Zip Code: Round Rock, TX 78665 93.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 94.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 95.Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 26 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 96.Name of the User: RRE Investors LP 97.What is the contact information for this User? Prefix (Mr. Ms. or Miss): First and Last Name: Karen Tunnell Suffix: Title: Credentials: Phone Number: 512-306-1771 Fax Number: Email: ktunnell@carrdevelopment.com Mailing Address: 5121 Bee Cave Rd, Ste. 207 City, State, and Zip Code: Austin, TX 78764 98.Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 99.Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 100. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/2o/2017) Page 27 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 101. Name of the User: Round Rock ISD 102. What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Selina Tovar Suffix: Title: Credentials: Phone Number: 512-464-5110 Fax Number: Email: Selina_tovar@roundrockisd.org Mailing Address: 1131 Round Rock Ave City, State, and Zip Code: Round Rock. TX 78664 103. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 104. Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 105. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ❑x Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 28 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 106. Name of the User: Texas A&M University 107. What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Alec Pointer Suffix: Title: Credentials: Phone Number: 979-862-8001 Fax Number: Email: apointer@tamu.edu Mailing Address: 1238 TAMU City, State, and Zip Code: College Station, TX 77843 108. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 109. Is there a contract, legal agreement, or ordinance between this user and the provider? ® Yes ❑ No If no, please explain: 110. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? N Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 29 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 111. Name of the User: Traditions at Vizcaya Community Association 112. What is the contact information for this User? Prefix (Mr. Ms. or Miss): First and Last Name: Olha Shockey Suffix: Title: Credentials: Phone Number: 737-209-8650 Fax Number: Email: oshockey@ccmcnet.com Mailing Address: 8360 E Via De Ventura L100 City, State, and Zip Code: Scottsdale, AZ 85258 113. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 114. Is there a contract, legal agreement, or ordinance between this user and the provider? Yes ❑ No If no, please explain: 115. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? D Yes ❑ No If no, please explain: TCEQ-20427(02/20/2017) Page 30 Authorization for Re-Use of Domestic Reclaimed Water Attachment A Additional Users Use this page if there are more than two users. Make additional copies as needed. 116. Name of the User: CCMC - Vizcaya Maintenance Association. Inc. 117. What is the contact information for this User? Prefix(Mr. Ms. or Miss): First and Last Name: Olha Shockey Suffix: Title: Credentials: Phone Number: 737-209-8650 Fax Number: Email: oshockey@ccmcnet.com Mailing Address: 8360 E Via De Ventura L100 City, State, and Zip Code: Scottsdale, AZ 85258 118. Types of Uses (irrigation, dust suppression, cooling water, etc): Irrigation 119. Is there a contract, legal agreement, or ordinance between this user and the provider? ►z Yes ❑ No If no, please explain: 120. Is the reclaimed water being supplied to the user on a "demand only" basis as required by 30 TAC §210.7? ® Yes ❑ No If no, please explain: TCEQ-20427(02/243/2o17) Page 31 Authorization for Re-Use of Domestic Reclaimed Water Instructions for Domestic Reclaimed Water Re- Use Authorization GENERAL INFORMATION Where to Send the Application Form BY REGULAR U.S. MAIL: BY OVERNIGHT/EXPRESS MAIL: Texas Commission on Environmental Texas Commission on Environmental Quality Quality Water Quality Division (MC-148) Water Quality Division (MC-148) P.O. Box 13087 12100 Park 35 Circle Austin, Texas 78711-3087 Austin, TX 78753 TCEQContact List Application- status and form questions: 512-239-4671 Technical questions: 512-239-4671 Environmental Law Division: 512-239-0600 Records Management- obtain copies of forms: 512-239-0900 Reports from databases(as available): 512-239-DATA(3282) Application Review Process When your application is received by the program, the form will be processed as follows: • Administrative Review: Each item on the form will be reviewed for a complete response. In addition, the producer and provider's legal name must be verified with Texas Secretary of State as valid and active (if applicable). The address(s) on the form must be verified with the US Postal service as receiving regular mail delivery. Do not give an overnight/express mailing address. • Technical Review: The form and attachments will be reviewed to determine compliance with 30 TAC §210. • Notice of Deficiency: If an item is incomplete or not verifiable as indicated above, a notice of deficiency(NOD) will be mailed to the application contact. The application contact will have 30 days to respond to the NOD. The response will be reviewed for completeness. • Acknowledgment of Coverage: A reuse authorization will be mailed to the provider. OR • Denial of Coverage: If the application contact fails to respond to the NOD or the response is inadequate, authorization may be denied. If authorization is denied, the application contact will be notified. INSTRUCTIONS FOR FILLING OUT THE FORM Indicate if you are requesting a new authorization or an amendment of an existing TCEQ-20427(02/20/2017) Page 1 Instructions for Authorization for Re-Use of Domestic Reclaimed Water reuse authorization. If this is an amendment, please provide the reuse authorization number. The reuse authorization number will begin with the letter "R". Provide the permit number for the wastewater treatment plant. This number will begin with "WQ00". If the permit number provided is not active (ie. pending, cancelled, or expired), the reuse authorization will be denied. Section 1.and 2.Producer and Provider(Applicant) a) Customer Number(CN) TCEQ's Central Registry assigns each customer a number that begins with CN, followed by nine digits. This is not a permit number, registration number, or license number. The Customer Number is available at the following website: http://wwwl 5.tceq.texas.gov/crpub/. b) Legal Name of Applicant Provide the current legal name of the applicant. The name must be provided exactly as filed with the Texas Secretary of State, or on the legal documents forming the entity as filed with the county. If filed in the county, provide a copy of the legal documents showing the legal name. Section 3.Application Contact Provide the name, title and contact information of the person that TCEQ can contact for additional information regarding this application. Section 4.Regulated Entity(RE)Information a) Regulated Entity Reference Number(RN) The RN is issued by TCEQ's Central Registry to sites where an activity is regulated by TCEQ. This is not a permit number,registration number, or license number. Search TCEQ's Central Registry to find the wastewater treatment plant's assigned RN at http://wwwl 5.tceq.texas.gov/crpub/. Provide the assigned RN for the wastewater treatment plant where the reclaimed water is produced. b) Wastewater Treatment Plant Site Name Provide the site name for the Wastewater Treatment Plant that generates the wastewater. Section 5.General Characteristics a) Identify the type of reclaimed water that is used. b) Identify the treatment processes that may be needed to achieve the effluent quality for each type of reclaimed water used. c) Provide the requested information concerning the effluent limits in the wastewater discharge permit. TCEQ-20427(02/20/2017) Page 2 Instructions for Authorization for Re-Use of Domestic Reclaimed Water Section 6.Storage Requirements a) Indicate if the reclaimed water is stored in fabricated tanks. b) Indicate if the reclaimed water storage or usage sites are located in the Edwards Aquifer Recharge Zone. c) Indicate if any of the reclaimed water usage sites are located outside the Edwards Aquifer Recharge Zone, but within the DRASTIC Designated Areas having a pollution potential index figure of 110 or greater. d) Complete this set of questions if you answered YES to questions b or c in this section. e) Complete this set of questions if you answered NO to questions b or c in this section. Section 7.Reclaimed Water Uses a) Describe all of the potential uses of the reclaimed water at the WWTP. b) Describe all of the potential uses of the reclaimed water at other sites. Uses include, but are not limited to, landscape irrigation, irrigation of sports complexes, golf course irrigation, dust control, fire prevention, etc. Section 8,Reclaimed Water Users a) Indicate if the producer, provider, and user are the same entity. If Yes, attach the contract template and complete the questions in this section. If No, skip to section 9. b) Indicate if the contract includes an operation and maintenance plan. c) Provide the requested information about each user. If there are more than 2 users, • complete Attachment A. Section 9.Attachments Complete and attach the TCEQ Core Data Form(TCEQ-io400). Attach a map of the service area for the reclaimed water. Attach a map showing the location of all reclaimed water storage ponds. Attach a copy of each user contract,if the user is a different entity than the producer and provider. Attach a copy of the operation and maintenance plan for each contract. Section 10 and 11.Certifications The certification must bear an original signature of a person meeting the signatory requirements specified under 30 Texas Administrative Code §305.44. TCEQ-20427(02/2o/2017) Page 3 Instructions for Authorization for Re-Use of Domestic Reclaimed Water IF YOU ARE A CORPORATION: The regulation that controls who may sign an application form is 30 Texas Administrative Code §305.44(a), which is provided below. According to this code provision, any corporate representative may sign an NOI or similar form so long as the authority to sign such a document has been delegated to that person in accordance with corporate procedures. By signing the NOI or similar form,you are certifying that such authority has been delegated to you. The TCEQ may request documentation evidencing such authority. IF YOU ARE A MUNICIPALITY OR OTHER GOVERNMENT ENTITY: The regulation that controls who may sign an NOI or similar form is 30 Texas Administrative Code §305.44(a), which is provided below. According to this code provision, only a ranking elected official or principal executive officer may sign an NOI or similar form. Persons such as the City Mayor or County Commissioner will be considered ranking elected officials. In order to identify the principal executive officer of your government entity, it may be beneficial to consult your city charter, county or city ordinances, or the Texas statutes under which your government entity was formed. An NOI or similar document that is signed by a government official who is not a ranking elected official or principal executive officer does not conform to §305.44(a)(3). The signatory requirement may not be delegated to a government representative other than those identified in the regulation. By signing the NOI or similar form, you are certifying that you are either a ranking elected official or principal executive officer as required by the administrative code. Documentation demonstrating your position as a ranking elected official or principal executive officer may be requested by the TCEQ. If you have any questions or need additional information concerning the signatory requirements discussed above,please contact the Texas Commission on Environmental Quality's Environmental Law Division at 512-239-0600. 30 TEXAS ADMINISTRATIVE CODE §305.44. SIGNATORIES TO APPLICATIONS (a) All applications shall be signed as follows. (1) For a corporation, the application shall be signed by a responsible corporate officer. For purposes of this paragraph, a responsible corporate officer means a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation; or the manager of one or more manufacturing,production, or operating facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million(in second-quarter 1980 dollars), if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. Corporate procedures governing authority to sign permit or post-closure order applications may provide for assignment or delegation to applicable corporate positions rather than to specific individuals. (2) For a partnership or sole proprietorship,the application shall be signed by a general partner or the proprietor,respectively. (3) For a municipality, state, federal, or other public agency, the application shall be signed by either a principal executive officer or a ranking elected official. For purposes of this paragraph, a principal executive officer of a federal agency includes the chief executive officer of the agency, or a senior executive officer having TCEQ-20427(02/20/2017) Page 4 Instructions for Authorization for Re-Use of Domestic Reclaimed Water responsibility for the overall operations of a principal geographic unit of the agency (e.g.,regional administrator of the EPA). TCEQ-20427(02/20/2017) Page 5 Instructions for Authorization for Re-Use of Domestic Reclaimed Water