Loading...
CM-2004-026Notice of Intent (NOI) for Storm Water Discharges Associated with Construction Activity under the TPDES General Permit TCEQ Office Use Only TPDES Permit Number: TXR15 I 1— 1_ I_ GIN Number: J 1 I I I Fee Receipt No. TCEQ ► 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 fmal acknowledgment or coverage under the general permit. Application Fee: You must submit the $ l00 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 NoJBldg.No.: City: ROUND ROCK ZIP Code: 78664 — Phone No.: ( 512 ) 218-5555 Extension: N/A 5. FAX No. 512-218-7097 E-mail Address: steve@bg1000.com 6. Type of Operator: al Individual Corporation County Government l Sole Proprietorship-D.B.A. Federal Govemment City Government * 111I Partnership State Government Other: 7. Independent Operator: l Yes No (If governmental entity or a subsidiary or part of a larger corporation, check "NO") 8. Number of Employees: * 0-20; 21-100; 1 101-250; a 251-500; or * 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) P".• ....;. .e,. r ra t l�Fie.'k :.:t S'*,.. .. E k.. ... <4... < ,. >.. > ...sv..., :. caN E. .; S:. d 4 .'H.,t-a �. .bb... e av ., " .. ...�...K. � .k,:rr N,i � .:5�. '� 3F C g"v"S'+�< "�".a"iS' x=w.:1..y:�.,...s�.�r3,ady ¢ >�e 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: Suite No./Bldg.No.: City: State: ZIP Code: 2. Billing Contact (Attn or C/O): 3. Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: .4. Phone No.: ( ) - Extension: .,. FAX No. E-mail Address: ..,,,. kms.. ... x... . : ., .E...''.^ac <:.. , .. .<, .; ,�_�..a.._..-< .�. a•.a.:.� ..x.?.,� .- ... x�i ..,:.,,� ._.a°' ,,,..,. �..,,,.,. ..__.,. _ .., ., - t -� i .;. �� . ?C✓� ... k� "..: _... ... >~.. ,.... f . ,.,: :. .:r K ,,. ».. f... � ''..s. s� ._.. r�i' . Wt.-.<_�u, ,3;.<.�'�„�a'iT � n. r�-�: �?s< .?, R �i 'v.w::7..z d.,< a,�..n., `�,v., ,c6,.`�,.:d'..k.,�d r t3N-:: 9w �wi.� to�, 3....i .i� i +.�'�' �,. �x`e 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 2. Phone No.: ( 512 ) 930-7733 Title: OFFICE MANAGER Company: COMPLIANCE RESOURCES, INC. 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: CR 122 STREET IMPROVEMENTS (PH 1 & 2) & 16" EAST WATER TRANSMISSION LINE(PH 3A.1) 3. Physical Address of Project or Site: (enter in spaces below) Street Number: 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) SOUTH OF THE INTERSECTION OF COUNTY ROAD 122 ( RED BUD LANE) AND HIGHWAY 79 5. Latitude: 30°31'55" N Longitude: 097°36'51" 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): STREET IMPROVEMENTS AND TRANSMISSION LINE 8. Is the project/site located on Indian Country Lands? 0 Yes ®' No If Yes, you must obtain authorization through EPA, Region VI. E. SITE MAILING ADDRESS (address for receiving mail at the site) 0 Same As Operator (check if address is the same, then proceed with Section F.) Mailing Address: City: F. GENERAL CHARACTERISTICS Suite No./Bldg.No.: State: ZIP Code: 1. Has a Pollution Prevention Plan been prepared as required in the general permit? 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): 24 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: BRUSHY CREEK Segment: TCEQ-20022 (07/12/2004) Page 2 of 3 CERTIFICATION 1, James R.,Nuse Typed or printed name I 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 of suc r author' ation upon request. Signature: Date: (0.0s.‘, czt„.1_,z,u e e.. Low-vc_ , i — 2 (2- 0 �{ TCEQ-20022 (07/12/2004) Page 3 of 3 Storm Water Pollution Prevention Plan For County Road 122 Street Improvements (Phase 1 and 2) and 16" East Water Transmission Line (Phase 3A.1) Cash Construction Company, Ltd. 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 P.E., City Manager City of Round Rock S. nature Phone Number (512) 218-501 Date �z1zj)lo+ Page 4 COPYRIGHT © 2004 COMPLIANCE RESOURCES, INC. 512.930.7733 Storm Water Pollution Prevention Plan For County Road 122 Street Improvements (Phase 1 and 2) and 16" East Water Transmission Line (Phase 3A.1) Cash Construction Company, Ltd. 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 Phone Number Gary L. Stewart, Vice President (512) 251-7872 Cash Co struction Comp, Ltd. 410 AmL.c.ii1111111 Sign Page 5 Date COPYRIGHT © 2004 COMPLIANCE RESOURCES, INC. 512.930.7733