CM-2015-810 - 6/12/2015TCEQ Use Only
TCEQ Core Data Form
For detailed instructions regarding completion of this form, please read the Core Data Form Instructions or call 512-239-5175.
SECTION 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)
1 ❑ Other
❑Owner ❑ Operator ® Owner & Operator
❑Occupational Licensee ❑ Responsible Party ❑ Voluntary Cleanup Applicant ❑Other:
2. Attachments Describe Any Attachments: ex. Title VApplication, Waste TranspoderApplication, etc.
®Yes ❑No
I Exception Request
3. Customer Reference Number if issued)
Follow this link to search
4. Regulated Entity Reference Number if issued
CN 600413191
for CN or RN numbers in
RN
Central Registry"
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
6. Customer Role (Proposed or Actual) - as it relates to the Regulated Entity listed on this form. Please check only one of the following:
❑Owner ❑ Operator ® Owner & Operator
❑Occupational Licensee ❑ Responsible Party ❑ Voluntary Cleanup Applicant ❑Other:
7. General Customer Information
❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership
❑Change in Legal Name (Verifiable with the Texas Secretary of State) ® No Change"
"If "No Change" and Section I is complete, skip to Section III - Regulated Entity Information.
8. Type of Customer:
❑ Corporation
❑ Individual
❑ Sole Proprietorship- DRA
❑ City Government
❑ County Government
❑ Federal Government
❑ State Government
❑ Other Government
❑ General Partnership
❑ Limited Partnership
❑ Other:
9. Customer Legal Name (If an individual, print last name first: ex: Doe, John) If new Customer. enter previous Customer End Date:
below
10. Mailing
Address:
City
State
ZIP
ZIP + 4
11. Country Mailing Information (ffoutside usA)
12. E -Mail Address (ifapplicable)
13. Telephone Number 14. Extension or Code 15. Fax Number (if applicable)
16. Federal Tax ID (9dryna) 17. TX State Franchise Tax ID pi digs) 18. DUNS Number(iapWtcaue) 19. TX SOS Filing Number gfapprrable)
20. Number of Employees 21. Independently Owned and Operated?
[-10-20 ❑21-100 ❑ 101-250 ❑ 251-500 ❑ 501 and higher ❑ Yes ❑ No
SECTION III: Regulated Entity Information
22. General Regulated Entity Information (If 'New Regulated Entity" is selected below this form should be accompanied by a permit application)
® New Regulated Entity ❑ Update to Regulated Entity Name ❑ Update to Regulated Entity Information ❑ No Change" (see below)
"If "NO CHANGE" Is checked and section I is complete, skip to Section w, Preparer Information.
23. Regulated Entity Name (name of the site where the regulated action is taking place)
STELLA PARK IMPROVEMENT PROJECT
TCEQ-10400 (09107) Page 1 of 2
24. Street Address
of the Regulated
Entity:
(No P.O. Boxes)
803 NANCY DRIVE
36. Nearest City
City
ROUND ROCK
State
TX
I ZIP
1 78664
ZIP + 4
78664
25. Mailing
Address:
CITY OF ROUND ROCK - PARKS AND RECREATION DEPARTMENT
301 W. BAGDAD, SUITE 250
City
I ROUND ROCK
State
I TX
ZIP
1 78664
ZIP + 4
❑ Title V -Air
26. E -Mail Address:
dbuzzell@roundrocktexas.gov
27. Telephone Number 28. Extension or Code 29. Fax Number (ifappacable)
( 512 ) 341-3345
1
1 ( 512 ) 218-5548
30. Primary SIC Code (4 digits) 31. Secondary SIC Code (4 digits) 32. Primary NAICS Code 33. Secondary NAICS Code
5 or 6 d' its 5 or 6 digits)
34. What is the Primary Business of this entity? (Please do not repeat the SIC or NAICS description.)
OUTDOOR RECREATION - PARK
Questions 34 - 37 address aeoaranhic location. Please refer to the instructions for anolicability.
35. Description to
Physical Location:
NORTH ON I-35 FROM AUSTIN. TAKE HWY 79 EXIT. GO EAST ON HWY 79
(RIGHT TURN). TURN LEFT ON EGGER AVE. TURN RIGHT ON NANCY DRIVE
36. Nearest City
❑ Industrial Hazardous Waste
County State Nearest ZIP Code
ROUND ROCK
Phone:
( 512) 218-5410
WILLIAMSON
TX
78664
37. Latitude (N) In Decimal:
130.524150
38. Longitude (W) In Decimal:
-97.673230
Degrees
Minutes I
Seconds Degrees I Minutes Seconds
30
31 1
25.3 -97 140 23.9
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 or the
uadates may not be made. If your Program is not listed, check other and write it in. See the Core Data Form instructions for additional guidance.
❑ Dam Safety
❑ Districts
® Edwards Aquifer
❑ Industrial Hazardous Waste
❑ Municipal Solid Waste
Laurie Wdley
Phone:
( 512) 218-5410
Signature:
0
❑ New Source Review - Air
❑ OSSF
❑ Petroleum Storage Tank
❑ PWS
❑ Sludge
❑ Stormwater
❑ Title V -Air
❑ Tires
❑ Used Oil
❑ Utilities
❑ Voluntary Cleanup
❑ Waste Water
❑ Wastewater Agriculture
❑ Water Rights
❑ Other:
SECTION IV: Prevarer Information
40. Name: I David Buzzell 1 41. Title: I Assistant Director
42. Telephone Number 43. Ext./Code 44. Fax Number 45. E -Mail Address
( 512 ) 341-3345 1 1 ( 512 ) 218-5548 dbuzzell@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 9 and/or as required for the
updates to the ID numbers identified in field 39.
(See the Core Data Form instructions for more information on who should sign this form.)
Company:
City of Round Rock
Job Title:
I City Manager
Name(in Print) :
Laurie Wdley
Phone:
( 512) 218-5410
Signature:
0
Date:
� ./2• /
— � v
TCEQ-10400 (09107) Page 2 of 2
Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
I Laurie Hadley ,
Print Name
City Manager ,
Title - Owner/President/Other
of the City of Round Rock ,
Corporation/Partnership/Entity Name
have authorized David Buzzell
Print Name of Aae
gineer
of City of Round Rock — PARD
Print Name of Firm
to represent and act on the behalf of the above named Corporation, Partnership, or Entity for
the purpose of preparing and submitting this plan application to the Texas Commission on
Environmental Quality (TCEQ) for the review and approval consideration of regulated
activities.
I also understand that:
1. The applicant is responsible for compliance with 30 Texas Administrative Code
Chapter 213 and any condition of the TCEQ's approval letter. The TCEQ is authorized
to assess administrative penalties of up to $10,000 per day per violation.
2. For those submitting an application who are not the property owner, but who have the
right to control and possess the property, additional authorization is required from the
owner.
3. Application fees are due and payable at the time the application is submitted. The
application fee must be sent to the TCEQ cashier or to the appropriate regional office.
The application will not be considered until the correct fee is received by the
commission.
4. A notarized copy of the Agent Authorization Form must be provided for the person
preparing the application, and this form must accompany the completed application.
5. No person shall commence any regulated activity on the Edwards Aquifer Recharge
Zone, Contributing Zone or Transition Zone until the appropriate application for the
activity has been filed with and approved by the Executive Director.
TCEQ-0599
(',M Zoe S Flo
SIGNATURE PAGE:
Kum , m ff�t'
- .• I
THE STATE OF §
r
County of1.)kIrvLpr-) §
(4p./21- /Ir.�
Date
BEFORE ME, the undersigned authority, on this day personally appeared�-A"c nown
to me to be the person whose name is subscribed to the foregoing instrument, and acknowle ged to
me that (s)he executed same for the purpose and consideration therein expressed.
GIVEN under my hand and seal of office on this /2,-PdAay of I .'za-S7'
rp�,� MONIM f WAMS
W COMMISSION EXPIRES
TCEQ-0599
NOTARY PLPLIC
/yoNl Q�cE A��-iS
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: qItD10ir
City of Round Rock
T XAS ND aOQ� Agenda Item Summary
Agenda Number:
Title: Consider executing TCEQ "Agent Authorization Form For Required
Signature Edwards Aquifer Protection Program Relating to 30 TAC
Chapter 213" authorizing David Buzzell to represent and act on behalf of
the City regarding the Stella Park Improvement Project.
Type: City Manager Item
Governing Body: City Manager Approval
Agenda Date: 6/12/2015
Dept Director: Rick Atkins, Director
Cost:
Indexes:
Attachments: LAF - TCEQ Edwards Aquifer Protection Program -
(00336202xA08F8).pdf, Bacukp
TCEQ-AGENT-AUTHOR IZATI ON—FORM. DOC, Backup TCEQ Core
Data.doc
Department: Parks and Recreation Department
Text of Legislative File CM -2015-810
City of Round Rock Page 1 Printed on 612/2015
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: PARD Project Name: Stella Park Improvement
Project Mgr/Resource: Katie Baker Contractor/Vendor: Texas Commission on Environmental
Council Action:
ORDINANCE F—I RESOLUTION
Agenda Wording
xx City Manager Approval
l.lylHyyoraing
Consider executing TCEQ "Agent Authorization Form For Required Signature Edwards Aquifer Protection Program Relating to 30
TAC Chapter 213" authorizing David Buzzell to represent and act on behalf of the City regarding the Stella Park Improvement
Project.
Attorney Approval
[EfAttorney
Date / J
O:\wdox\SCClnts\0123\1500\M ISC\00336202.XLS Updated 6/3/08