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CM-2004-021. _ Notice of Intent (NO1) for Storm Water wr Discharges Associated with Construction 11111110 Activity under the TPDES General Permit firms rcE42 TCEQ Office Use Only TPDES Permit Number: TXR15IIIII GIN Number: I I I I I Fee Receipt No. IMPORTANT: •Use the attached INSTRUCTIONS when completing this form. •After completing this form, use the attached CUSTOMER CHECKLIST to make certain all items are complete and accurate. -Missing, illegible, or inaccurate items may delay final acknowledgment or coverage under the general permit. Application Fee: You must submit the $100 NOI Application Fee to TCEQ under separate cover (see instructions) using the attached Application Fee submittal form. (DO NOT SEND A COPY OF THE NOI WITH THE APPLICATION FEE SUBMITTAL FORM) Tell us how you paid for this fee: Check/Money Order No.: Name Printed on Check: A. OPERATOR 1. TCEQ Issued Customer Number (CN) (if available): 600413181 2. Legal Name (spelled exactly as filed with the Texas Secretary of State, County, or legal document that was used in forming the entity): CITY OF ROUND ROCK 3. Mailing Address: 2008 ENTERPRISE DRIVE Suite No./Bldg.No.: City: ROUND ROCK 4. Phone No.: ( 512 ) 218-5555 State: TX ZIP Code: 78664 Extension: N/A 5. FAX No. 512-218-7097 E-mail Address: steve@bg1000.com 6. Type of Operator: 0 Individual 0 Sole Proprietorship-D.B.A. 0 Partnership 0 Corporation 0Federal Government 0State Government 0 County Government City Government Other: 7. Independent Operator: 0 Yes No (If governmental entity or a subsidiary or part of a larger corporation, check "NO") 0 8. Number of Employees: 0 0-20; 0 21-100; 0 101-250; ) 251-500; or 0 501 or higher 9. Business Tax and Filing Numbers (not applicable to Individuals, Government, General Partnerships, and Sole Proprietorship-D.B.A): State Franchise Tax ID Number: N/A Federal Tax ID: 26-001074 TX SOS Charter (filing) Number: N/A DUNS Number: N/A (If known) B. BILLING ADDRESS (The Operator is responsible for paying the annual fee.) 0 Same As Operator (check if address is the same, then proceed with Section C.) 1. Billing Mailing Address: City: IState: Suite No.B1dg.No.: 2. Billing Contact (Attn or C/O): IZIP Code: 3. Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: 4. Phone No.: ( ) Extension: 5. FAX No. E-mail Address: TCEQ-20022 (07/12/2004) Page 1 of 3 C. APPLICATION CONTACT (If TCEQ needs additional information regarding this application, who should be contacted? 1. Name: MISTI SHAFER Title: OFFICE MANAGER Company: COMPLIANCE RESOURCES, INC. 2. Phone No.: ( 512 ) 930-7733 Extension: N/A 3. FAX No. 512-864-7629 E-mail Address: misti@complianceresourcesinc.com D. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE 1. TCEQ Issued RE Reference Number (RN) (if available): 2. Name of Project or Site: AVERY FARMS WASTEWATER INTERCEPTOR 3. Physical Address of Project or Site: (enter in spaces below) Street Number: Street Name: City (nearest to the site): ROUND ROCK ZIP Code (nearest to the site): 78664 County (Counties if >1): WILLIAMSON 4. If no physical address (Street Number & Street Name), provide a written location access description that can be used for locating the site: (Ex.: 2 miles west from intersection of Hwy 290 & IH35 on Hwy 290 South) ALONG THE WEST SIDE OF FM 1460 FROM CHANDLER ROAD TO OLD SETTLERS BLVD. 5. Latitude: 30°34'07" N Longitude: 097°39'05" W 6. Standard Industrial Classification (SIC) code: 1623 7. Describe the activity related to the need for this authorization at this site (do not repeat the SIC and NAICS code): WASTEWATER INTERCEPTOR 8. Is the project/site located on Indian Country Lands? 0 Yes 0 No If Yes, you must obtain authorization through EPA, Region VI. E. SITE MAILING ADDRESS (address for receiving mail at the site) El Same As Operator (check if address is the same, then proceed with Section F.) Mailing Address: City: State: Suite No.Bldg.No.: F. GENERAL CHARACTERISTICS ZIP Code: 1. Has a Pollution Prevention Plan been prepared as required in the general permit? Ill Yes 0 No If No, coverage may be denied as the PPP is required at the time the NOI is submitted to TCEQ. 2. Provide the estimated area of land disturbed (to the nearest acre): 23 Acres 3. Provide the name of the receiving water body (local stream, lake, drainage ditch), MS4 Operator (if applicable) and the segment number where storm water runoff will flow from the construction site. MS4 Operator: CITY OF ROUND ROCK Receiving Water Body: MCNUTT CREEK Segment: TCEQ-20022 (07/12/2004) Page 2 of 3 CERTIFICATION I, James -R-. Nuse Typed or printed name CITY MANAGER Title (Required) 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 o uch au orization upon request. Signature: TCEQ-20022 (07/12/2004) (Use Blue Ink) e A/1 - p. 0 a Date: Page 3 of 3 Storm Water Pollution Prevention Plan For Avery Farms Wastewater Interceptor Schroeder Construction II. SWP3 Certification Authority Signature "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 gathered and evaluated 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 that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." Authority Representative Name and Title James R. Nuse, City Manager City of Round Rock Signa Phone Number (512)218 5401 Date Page 3 11 o COPYRIGHT © 2004 COMPLIANCE RESOURCES, INC. 512.930.7733 • C. CERTIFICATION Roubert A. Schroeder Typed or printed name General Partner Title (Required) 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 ofmy 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 at I am auto er 30 Texas Administrative Code §305.44 to sign and submit this document, and can provide documentation in proof of suc Signature. `• / ` ` Date: (Use Blue In 71 'of w TCEQ-20022 (07/12/2004) Avery Farms Job No. 525 CERTIFIED MAIL #7003 1010 000408578 8639 Pagc 3 of 3