CM-2004-020Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
SP.tMES R• Nu,SC
Print Name
C T� NPAG-EQ
Title - Owner/President/Other
of City of Round Rock
Corporation/Partnership/Entity Name
have authorized Adam M. Ramirez
Print Name of Agent/Engineer
of Fisher Hagood, Inc.
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 Natural Resource
Conservation Commission (TNRCC) for the review and approval consideration of regulated
activities.
also understand that:
1. The applicant is responsible for compliance with 30 Texas Administrative Code Chapter
213 and any condition of the TNRCC's approval letter. The TNRCC is authorized to
assess administrative penalties of up to $10,000 per day per violation.
2. A notarized copy of the Agent Authorization Form must be provided for the person
preparing the application, and the forms must accompany the completed application.
3. Application fees are due and payable at the time the application is submitted. The
application fee must be sent to the TNRCC cashier or to the appropriate regional office.
The application will not be considered until the correct fee is received by the commission.
TNRCC-0599 (Rev.5/01/02)
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4. For applicants who are not the property owner, but who have the right to control and
possess and control the property, additional authorization is required from the owner.
App is Signature Date
THE STATE OF TEXAS
County of Williamson §
BEFORE ME, the undersigned authority, on this day personally appeared , known
to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me
that he executed same for the purpose and consideration therein expressed.
GIVEN under my hand and seal of office on this day of September, 2004.
NOTARY PUBLIC
Typed or Printed Name of Notary
MY COMMISSION EXPIRES:
TNRCC-0599 (Rev,5/01/02)
CM - D)4(- cp C)
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Texas Natural Resource Conservation Commission
Edwards Aquifer Protection Plan
Application Fee Form
NAME OF PROPOSED REGULATED ENTITY: City of Round Rock — Parks and Recreation Department Service
Yard Site
REGULATED ENTITY LOCATION: 300 So. Burnet Street
NAME OF CUSTOMER: City of Round Rock
CONTACT PERSON: Larry Madsen PHONE: (512) 218-5552
(Please Print)
Customer Reference Number (if issued): CN (nine digits)
Regulated Entity Reference Number (if issued): RN (nine digits)
AUSTIN REGIONAL OFFICE (3373)
❑ Hays
El Travis
❑ Williamson
SAN ANTONIO REGIONAL OFFICE (3362)
❑ Bexar 0 Medina
❑ Comal 0 Uvalde
❑ Kinney
APPLICATION FEES MUST BE PAID BY CHECK, CERTIFIED CHECK, OR MONEY ORDER, PAYABLE TO THE
TEXAS NATURAL RESOURCE CONSERVATION COMMISSION. YOUR CANCELED CHECK WILL SERVE AS
YOUR RECEIPT. THIS FORM MUST BE SUBMITTED WITH YOUR FEE PAYMENT. THIS PAYMENT IS BEING
SUBMITTED TO (CHECK ONE):
❑ SAN ANTONIO REGIONAL OFFICE
❑ Mailed to TNRCC:
TNRCC - Cashier
Revenues Section
Mail Code 214
P.O. Box 13088
Austin, TX 78711-3088
AUSTIN REGIONAL OFFICE
0 Overnight Delivery to TNRCC:
TNRCC - Cashier
12100 Park 35 Circle
Building A, 3rd Floor
Austin, TX 78753
512/239-0347
Fee Due
$
$
$250.00
Date
uals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in
nformation corrected. To review such information, contact us at 512/239-3282.
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TNRCC-0574 (Rev. 05/01/02)
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Type of Plan
Size
Water Pollution Abatement, One Single Family
Residential Dwelling
Acres
Water Pollution Abatement, Multiple Single
Family Residential and Parks
Acres
Water Pollution Abatement, Non-residential
Acres
Sewage Collection System
L.F.
Lift Stations without sewer lines
Acres
Underground or Aboveground Storage Tank
Facility
Tanks
Piping System(s)(only)
Each
Exception
1
Each
Extension of Time
Each
Fee Due
$
$
$250.00
Date
uals are entitled to request and review their personal information that the agency gathers on its forms. They may also have any errors in
nformation corrected. To review such information, contact us at 512/239-3282.
C/VI-Loci 0
TNRCC-0574 (Rev. 05/01/02)
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Texas Natural Resource Conservation Commission
Edwards Aquifer Protection Program
Application Fee Schedule
30 TAC §213.14 (effective 11/14/97) & 30 TAC §213.9 (effective 6/1/99)
Water Pollution Abatement Plans and Modifications
PROJECT
PROJECT AREA IN
ACRES
FEE
One Single Family Residential Dwelling
<5
Multiple Single Family Residential and Parks
<5
5 < 10
10 < 50
>50
Non-residential (Commercial, industrial, institutional,
multi -family residential, schools, and other sites
where regulated activities will occur)
<1
1<5
5 < 10
>_10
$500
$1,000
$2,000
$3,000
$5,000
$2,000
$3,000
$4,000
$5,000
Organized Sewage Collection Systems and Modifications
PROJECT
COST PER LINEAR FOOT
Sewage Collection Systems
$0.50
MINIMUM FEE
MAXIMUM FEE
$500 - $5,000
Underground and Aboveground Storage Tank System
Facility Plans and Modifications
PROJECT
COST PER TANK OR
PIPING SYSTEM
Underground and Aboveground Storage Tank
Facility
$500
MINIMUM FEE
MAXIMUM FEE
$500 - $5,000
Exception Requests
PROJECT
FEE
Exception Request
$250
Extension of Time Requests
PROJECT
FEE
Extension of Time Request
$100
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TNRCC-0574 (Rev. 05/01/02)
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