CM-06-04-060_!VIM Notice of Termination (NOT) for Storm
C Water Discharges Associated with
NNW Construction Activity under the TPDES
TCEQ Office Use Only
TPDES Permit Number: TXR15•• •• •• •• •.- NO
GIN Number: •• •• •• •• •• •• •• ••
Construction General Permit (TXR150000)
TCEQFor help completing this application, read the TXR150000 NOI Instructions (TCEQ-20023-Instructions).
A. TPDES Permit Number: TXR15 H073
B. Construction Site Operator Customer Reference Number: CN CN6004131
Name: City of Round Rock
Mailing Address: 2008 ENTERPRISE DRIVE
City: ROUND ROCK State: TX Zip Code: 78664
Country Mailing Information (if outside USA) Territory: N/A Country Code: N/A Postal Code: N/A
Phone Number: (512) 218-5555 Extension: N/A Fax Number: (512) 218-5563
E-mail Address: rhaberman(dround-rock.tx.us
C. Project / Site Information Regulated Entity Reference Number: RN 104085980
Name: CITY OF ROUND ROCK SENIOR ACTIVITY CENTER
Physical Address: N/A
Location Access Description: 303 WEST BAGDAD
City: ROUND ROCK County: WILLIAMSON Zip Code: 78664
D. Contact - If the TCEQ needs additional information regarding this termination, who should be contacted?
Name: Ruth Haberman. P.E. Title: Engineer
Phone Number: (512) 218-6605 Extension: N/A Fax Number: (512) 218-5563
E-mail Address: rhabermanaround-rock.tx.us
E. Certification
I certify under penalty of law that authorization under the TPDES Construction General Permit (TXR150000) is no longer
necessary based on the provisions of the general permit. I understand that by submitting this Notice of Termination, I am
no longer authorized to discharge storm water associated with construction activity under the general permit TXR150000,
and that discharging pollutants in storm water associated with construction activity to waters of the U.S. is unlawful under
the Clean Water Act where the discharge is not authorized by a TPDES permit. I also understand that the submittal of this
Notice of Termination does not release an operator from liability for any violations of this permit or the Clean Water Act.
Construction Site Operator Representative:
Prefix: MR. First: JAMES Middle: R.
Last: NUSE Suffix: P.E.
Title: CITY ,`ANAGER
Signature:
N r Date: ``/ -1 -06,
If you have q
Individuals are
also have any
TCEQ - 20023 (02/03)
/1.4 sl/ /1// /\/
- -tions on how to fill out this form or about the storm water program, please contact us at (512) 239-4671.
entitled to request and review their personal information that the agency gathers on its forms. They may
errors in their information corrected. To review such information, contact us at (512) 239-3282.
The completed NOT must be mailed to the following address:
Texas Commission on Environmental Quality
Storm Water & General Permits Team; MC - 228
P.O. Box 13087
Austin, Texas 78711-3087
Page 1 of 1
l\ _
DATE: April 3, 2006
SUBJECT: City Manager Approval - April 7, 2006
ITEM: Consider an action by the City Manager to sign a Notice of
Termination (NOT) for Storm Water Discharges
Associated with Construction Activity under the TPDES
General Permit for the City of Round Rock Senior Activity
Center project.
Department: Engineering & Development Services
Staff Person: Ruth Haberman, P.E.
Justification:
Construction of this project has been completed. The Notice of Termination,
signed by the City Manager, must be sent to the Texas Commission on
Environmental Quality (TCEQ) to close out the project.
Funding:
Cost: -0-
Source of funds: N/A
Outside Resources: N/A
Background Information: N/A
Public Comment: N/A
Request for City Council/City Manager Action
PI City Council 0 City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Engineering & Development Services Project Name: Senior Activity Center
For Administration Use ONLY
Recei 1114t44(C
Tag #
Original Documents Received:
Contact Person: Latha Kumar/Tiffany Calley ContractorNendor:
Project
Manager/Resource:
Project Coordinator: Ruth Haberman, P.E.
Assigned Attomey:
Blue Sheet wording
Council or City Manager Approval Date:
Funding Source:
Amount:
Account Number:
4/7/2006
$0.00
Consider an action by the City Manager to sign a Notice of Termination (NOT) for Storm Water Discharges Associated with Construction Activity under the TPDES
General Permit for the City of Round Rock Senior Activity Center project.
Finance Information
Is Funding Required?® Yes ® No
0
Purchasing/Service Agreement
Initial Construction Contract
Construction Contract Amendment #
Change Order
Change in Quantify
Unforeseen Circumstances
Initial Professional Services Agreement
Supplemental Professional Svcs. AI
Purchase Order
Item(s) to be purchased:
Amount
Other (Please clearly identify action on lines below)
City Manager's signature on the Notice of Termination.
Finance Approval
Finance Date
Finance Date
EJPurchasing Date
!Budget pate
Reauired for Submission of Citv Council and City Marlaaer Items
Project Mgr. Signature:
Dept. Director Signature.
City Attorney Signature*:
City Manager Signature:
Date:
5446
Date: 41S/06
Date: d 06
• Date: V (11
Legal is required for ell items.
Updated 2/18/06
Request for City Council/City Manager Action
0 City Council Ej City Manager
For Administration Use ONLY
Received:
Tag*
Submit completed form for all City Manager and City Council approvals.
Department Name: Engineering & Development Services
Contact Person: Latha Kumar/Tiffany Calley
Project
Original Documents Received:
Project Name: Senior Activity Center
ContractorNendor:
Manager/Resource: Funding Source:
Project Coordinator: Ruth Haberman, P.E. Amount
Assigned Attorney: Account Number:
Blue Sheet Wording
$0.00
Council or City Manager Approval Date: 4/7/2006
Consider an action by the City Manager to sign a Notice of Termination (NOT) for Storm Water Discharges Associated with Construction Activity under the
TPDES General Permit for the City of Round Rock Senior Activity Center project.
Finance Information
Is Funding Required? Q Yes 0 No
0
EJ
0
Purchasing/Service Agreement
Initial Construction Contract
Construction Contract Amendment #
Change Order
Change in Quantity
Unforeseen Circumstances
Initial Professional Services Agreement
Supplemental Professional Svcs. Al #
Purchase Order
Item(s) to be purchased:
Amount
Other (Please clearly identify action on lines below)
City Managers signature on the Notice of Termination.
Finance Approval
Finance n/a L. Olsen Date 4/5/2006
Finance Date
Purchasing N/A HB Date 4/5/2006
Budget N/A CYD Date 4/4/2006
Required for Submission of ALL City Council and City Manager Items
Project Mgr. Signature: Date:
Dept. Director Signature: Date:
City Attorney Signature*: Date:
City Manager Signature: Date:
* Legal Approval Is required for all (terns.
Updated 2/16/06