CM-2003-004e.m. aa,-
rii Notice of Intent (NO1) for Storm Water Discharges
— Associated with Industrial Activity under the
MITPDES Multi -Sector General Permit (TXR050000)
TNRCCFor help completing this application, read the TXR050000 NOI
TNRCC Use Only 1111
(�
TPDES Permit Number
GIN Number: •• •• •• •• •• ••
Central Registry Mail Number: ••
1 0
•• •• -'-
•• ••
•• •• •• ••
NO
••
Instructions (TNRCC-10382-Instructions).
A. Facility Owner Information
0
New
■
No Change Customer Reference Number. CN
Name: CITY OF ROUND ROCK
Mailing Address: 221 E. MAIN STREET
Address Line 2:
City: ROUND ROCK
State: TX Zip Code: 78664
Country Mailing Information (if outside USA)
Territory: Country Code: Postal Code:
Phone Number: (512) 218-5401
Extension: Fax Number: (512) 218-7097
E-mail Address:
Type of Owner:
❑ State Government
■
Individual
■
County
■
Sole Proprietorship
Govemment
0
- D.B.A.
City Govemment
■
Partnership
■ Other.
■
Corporation
■
Federal Govemment
Independent Owner?
Number of Employees:
Federal Tax ID: 746017485
■ Yes
■
0-20
•
No
■
21-100
State
Franchise
■
101-250
Tax ID
■
Number:
251-500
0
501 or higher
DUNS Number.
B. Facility Operator Information
0
New
■
No Change Customer Reference Number. CN
Name: CITY OF ROUND
ROCK
- PUBLIC WORKS
DEPARTMENT
Mailing Address: 2008
ENTERPRISE
DRIVE
Address Line 2:
City: ROUND ROCK
State: TX Zip Code: 78664
Country Mailing Information
(ifoutside
USA) Territory:
Country Code: Postal Code:
Phone Number: (512)
218-5555
Extension:
Fax Number: (512) 218-5563
E-mail Address: mthaneteround-rock.tx.us
Type
■
of Operator.
State Govemment
•
Individual
•
County
■
Govemment
Sole Proprietorship
0
- D.B.A. 0
City Govemment
Partnership
■ Other:
■
Corporation
■
Federal Govemment
Independent Operator?
Number of Employees:
Federal Tax ID: 746017485
■
■
Yes
0-20
■
■
No
21-100
State Franchise
•
101-250
Tax ID
■
Number:
251-500
0
501 or higher
DUNS Number.
C. Billing Address
Name: CITY OF ROUND ROCK - FINANCE DEPARTMENT
Mailing Address: 221 E. MAIN STREET
Address Line 2:
City: ROUND ROCK State: TX Zip Code: 78664
Country Mailing Information (if outside USA) Territory: Country Code: Postal Code:
Phone Number: (512) 218-5430 Extension: Fax Number. (512) 218-5442
E-mail Address:
D. Facility Site Information
0
New
■
No Change Regulated Entity Reference Number: RN
Name: CITY OF ROUND ROCK ETJ
Physical Address:
Mailing Address:
City: ROUND ROCK County: WILLIAMSON Zip Code:
Phone Number. (512) 218-5401 Extension: Fax Number: (512) 218-7097
E-mail Address:
Latitude:''" N Longitude:"'" W Degrees (0), Minutes ('), and Seconds (")
Latitude: Longitude: — Decimal Form
TNRCC-10382 (Revised 03/02) Page 1 of 2
e.m. aa,-
Is the facility located on Indian Country Lands? ❑ Yes 0 No
Primary SIC Code: Secondary SIC Code:
Primary NAICS Code: 92 Secondary NAICS Code: 92119
Activity Code:
What is the primary business of this facility? (please do not repeat the SIC or NAICS description)
To provide a high quality of service to residents and businesses with the City of Round Rock.
Mark the square of each sector that applies to the industrial activity at your facility that is to be covered under this general
permit. These sectors are defined in general permit TXR050000.
❑ Sector A 0 Sector E 0 Sector I 0 Sector M 0 Sector Q 0 Sector U 0 Sector Y 0 Sector AC
❑ Sector B 0 Sector F 0 Sector J 0 Sector N 0 Sector R ['Sector V ❑ Sector Z 0 Sector AD
❑ Sector C 0 Sector G 0 Sector K 0 Sector 0 0 Sector S 0 Sector W 0 Sector AA
❑ Sector D 0 Sector H 0 Sector L 0 Sector P 0 Sector T 0 Sector X 0 Sector AB
Has a storm water pollution prevention plan been developed and implemented as specified in the MSGP? 0 Yes 0 No
Does the facility discharge storm water into: (must check `Yes" to at least one)
A receiving water? ['Yes 0 No
If yes, name of receiving water: Brushy Creek (95%). San Gabriel River (3%), AND Wilbarger Creek (2%)
Segment Number (optional):
A municipal separate storm sewer system (MS4)? ['Yes ❑ No
If yes, name of the MS4 operator. CITY OF ROUND ROCK - PUBLIC WORKS DEPARTMENT
E. Contact - If the TNRCC needs additional information regarding this application, who should be contacted?
Name: MICHAEL D. THANE Title: ENGINEER - PUBLIC WORKS DEPARTMENT
Phone Number: (512) 218-3236 Extension: Fax Number: (512) 218-5563
E-mail Address: mthaneekround-rock.tx.us
F. Certification
I certify under penalty of law that this document was 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.
Owner Representative:
Prefix: MR. First: JAMES Middle: R.
Last: NUSE Suffix: P.E.
Title: CI MA
Signature: Date: 3110
0-5
If you have • =stio on how to fill out this form or about the storm water program, please contact us at (512) 239-4671.
Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in their
information corrected. To review such information, contact us at (512) 239-3282.
Operator Representative:
Prefix: MR. First: THOMAS Middle: E.
Last: WORD Suffix: P.E.
Tide: DIRECTO OF T NSP A • ' SERVICES - PUBUC WORKS DEPARTMENT
Signature: •
��. Date: ././1 0/03
If you have questions on how to fill out this form /out the storm water program, please contact us at (512) 239-4671.
Individuals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in their
information corrected. To review such information, contact us at (512) 239-3282.
The completed NOI must be mailed to the following address along with a $100 application fee payable to the TNRCC:
Texas Natural Resource Conservation Commission
Storm Water & General Permits Team; MC - 214
P.O. Box 13088
Austin, Texas 78711-3088
TNRCC-10382 (Revised 03/02)
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