CM-09-10-219TCEQ- 20392 (08/14/2007)
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Notice of Change (NOC) to an Authorization TCEQ Office Use Only
for Storm Water Discharges from Small RN: No.:
Municipal Separate Storm Sewer Systems CN:
TCEQ (MS4) under the TPDES Phase II MS4 General
Permit (TXR040000)
***** IMPORTANT *****
PLEASE READ THE FOLLOWING INFORMATION AND INSTRUCTIONS BEFORE FILLING OUT THIS FORM.
The form will be returned for one of the following reasons:
1) the permit number is not provided, invalid, or no longer active,
2) a wet ink signature of person meeting signatory requirements for permittee is not provided,
3) the current permittee is not the applicant, and;
4) a requested change in operator name is not a legal name change .
THIS FORM CANNOT BE USED FOR A CHANGE IN OPERATOR. REFER TO YOUR GENERAL PERMIT.
What is the Permit Number of the authorization to be changed?
TXR04 0253
A. APPLICANT INFORMATION: Search Central Registry at www4.tceq.state.tx.us/crpub
1. Operator (Permittee)
a. What is the full Legal Name of the current Operator as on the authorization?
City of Round Rock MS4
b. What is the TCEQ Central Registry Customer Number assigned to this Operator?
CN 600413181
2. Permitted Site (required)
What is the TCEQ Central Registry Regulated Entity Number assigned for this permitted site?
RN 105569867
B. REQUESTED CHANGE TO PERMITTED INFORMATION
What
(Check
information has changed or needs corrected?
one or more of the sections being updated and enter the new information in the corresponding section of this form.)
Operator Legal Name Change with Texas Secretary of State (TX SOS).
(Note: Permits are not transferable. If a change in entity has occurred, this NOC is not attainable.)
Address and contact information for Operator, Billing for Annual Fee or Site Mailing Address.
n
Site Information (Regulated Entity)
(Note: Permits under a general permit are site specific. If a change in site location has occurred, this NOC is not attainable.)
pi I
Change To The Approved SWMP
1.
OPERATOR LEGAL NAME CHANGE
a.
What is the NEW active Legal Name with TX SOS or on other legal document?
New
Legal Name:
b.
(This
What is the TX SOS Filing Number for us to confirm this official name change?
is only applicable to Limited Partnership or Corporations.)
2. ADDRESS
& CONTACT INFORMATION CHANGE
a.
What
mailing address and/or contact information has changed? check one or more as applicable)
0
Operator
for permit correspondence
Site (RE) Mailing Address and contact information
U
Billing
address/contact for Receiving
Annual Fee Statement
b. If
you
•
•
selected more than one, is the information to be updated the same for each selection?
Yes — Provide the updated information in the fields below.
No — Attachment 1 of the NOC is attached to this form, to provide the different addresses.
ATTN or C/O:
Address:
Suite No./Bldg. No./Mail Code:
City:
State:
Zip Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
Phone No.: ( ) Ext:
Fax No.: ( )
E-Mail:
TCEQ- 20392 (08/14/2007)
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TCEQ- 20392 (08/14/2007)
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3. REGULATED ENTITY (RE) SITE INFORMATION CORRECTION or UPDATE
a. Updated or Corrected description of the regulated MS4 boundaries:
b. Other update to regulated entity information. Please explain.
4. CHANGE TO THE APPROVED SWMP
Check the
applicable item(s) to be changed or updated and complete the section for each item. Reference the attachment for each item.
Add the 7th Minimum Control Measure
Complete Attachment 2 of the NOC
Are you seeking to use the 7th MCM
(MCM) to the approved SWMP.
and the following question:
only in the regulated (urbanized) area?
2 of the NOC.
2 of the NOC and indicate YES to the following certification:
with all of the MCMs listed in this general permit, in the MS4's additional area where the 7th
YES
will result in denial.
Yes - Attach the MCM with Attachment
No — Attach the MCM with Attachent
I certify that the MS4 is in compliance
MCM will be utilized.
Failure to indicate YES to this certification
✓
Notice to update the approved SWMP
equivalent BMP.
Are the revisions to the approved SWMP
adding components, controls, or requirements to
the SWMP; or replacing a BMP with an
attached? I v wes, under attachment A
i
Request to update the approved SWMP,
alternate BMP.
Are the revisions to the approved SWMP
replacing a less effective or infeasible BMP specifically
identified in the SWMP with an
attached? ✓ Yes, under attachment B
Other requested changes to the approved SWMP requiring TCEQ approval.
Are the revisions to the approved SWMP attached? DYes, under attachment
C. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: Danny Halden P.E.
Title: CityEngineerCompany:
City of Round Rock
2. Phone No.: ( 512) 218-6610 Ext:
Fax No.: ( 512) 218-5563
E -Mail: dhalden@round-rock.tx.us
D. CERTIFICATION
Operator Certification:
I, Jamey -R . Muse., P.E . C' ml tc u
Typed or printed name (REQUIRED)
certify under penalty of law that this document and all attachments were prepared under my direction
designed to assure that qualified personnel properly gather and evaluate the information submitted.
who manage the system, or those persons directly responsible for gathering the information, the information
knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for submitting
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
documentati in proof of such authorization upon request.
Signature: Date: '0
Title (REQLED)
or supervision in accordance with a system
Based on my inquiry of the person or persons
submitted is, to the best of my
false information, including the
this document, and can provide
- 30-2009
(Use blue ink) (REQUIRED)
(REQUIRED)
TCEQ- 20392 (08/14/2007)
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DATE: October 28, 2009
SUBJECT: City Manager Approval —October 30, 2009
ITEM: Consider executing "Notice of Change Form" to amend the City's Storm Water
Management Program with TCEQ.
Department:
Staff Person:
Engineering Development Services
Danny Halden, P.E. City Engineer
Justification: Upon review of the City's Storm Water Management Program (SWMP) and
continued coordination with other City departments responsible for implementation of Best
Management Practices (BMP), staff has determined necessary changes to the SWMP. The
proposed changes will adjust activity schedules and replace BMPs with more effective BMPs.
Strategic Plan Relevance: Item is relevant to strategic Goal 29, providing for effective storm
water management.
Funding:
Cost: NA
Source of funds: NA
Outside Resources : NA
Public Comment : NA
UPDATED: October 19, 2009
10.19.09
Request for City CounciilCity Manager Action
® City Council OM City Manager,/
Submit completed form for all City Manager and City Council approvals.
Department Name: Engineering & Development Services
Contact Person: Chez Gordon / Kathy Michna
Project Mgr/Resource: Danny Heiden
Project Coordinator.
Assigned Attorney:
NA
NA
City Council or City Manager Approval Date:
Agenda Wording
For Ai
Received:
v
123?I (WYd�
Tag#: CA- 19 -Io -2l"1
Original Documents Received: 2
Project Name: MS4 Permit Notice of Change
ContractorNendor: NA
Funding Source:
Additional funding Source: NA
Amount: NA
Account Number: NA
10/30/2009
Consider executing "Notice of Change Form" to amend the City's Storm Water Management Program with TCEQ.
Finance Information
Is Funding Required?
Initial Construction Contract
Construction Contract Amendment
Change Urder
Change in Quantity
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Yes
No
9
9
EJUnforeseen Circumstances
Other (Please dearly identify action below)
Amount
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
FINANCE
N/A Approved
Finance/ClP Date
Finance/Acct Date
EJ ci Purchasing Date
Budget Date
1 1
Finance Director
Once approvals have been obtained, please forward the RFA. blue sheet, back up information and originals to City Secretary, Sara White.
ITEMS WILL NOT BE PLACED ON THE COUNCIL AGENDA WITHOUT FINANCE AND LEGAL APPROVAL PRIOR TO SUBMISSION.
Date
Reouired for Submission of ALL City Council and City Manager Items
Project Mgr. Signature:
Dept. Director Signatu
*City Attorney Signature:
City Manager Signature:
Date:
pEDate: 4211°9
Date: lri-30-0
Date: I O- 3OJ- O
`City Attorney signature is required for all items.
REVISED 10/23/2009
10.19 09
Request for City Council/City Manager Action
® City Council E1 City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Engineering & Development Services
Contact Person: Chaz Gordon / Kathy Michna
Project Mgr/Resource: Danny Halden
Project Coordinator:
Assigned Attorney:
NA
NA
City Council or City Manager Approval Date:
Agenda Wording
strat:on U
Received:
Tag #:
Original Documents Received:
Project Name: MS4 Permit Notice of Change
ContractorNendor: NA
Funding Source:
Additional funding Source: NA
Amount: NA
Account Number: NA
10/30/2009
Consider executing "Notice of Change Form" to amend the City's Storm Water Management Program with TCEQ.
Finance Information
Is Funding Required?
Yes
10
No
Initial Construction Contract
Construction Contract Amendment >x
Change Urder q
=Change in Quantity =Unforeseen Circumstances
Initial Professional Services Agreement
Supplemental Professional Service Agreement #
Purchasing/Service Agreement
EJ Purchase Order
Item(s) to be purchased
Other (Please clearly identify action below)
Amount
FINANCE
N/A Approved
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
Finance/CIP L.Otsen Date 10/28/2009
0 = Finance/Acct E. Wilson Date 10/28/2009
0 0 Purchasing EE Bowden Date 10/28/2009
0 = Budget P. Bryan Date 10/27/2009
Ix
Cheryl Delaney 10/28/2009
Finance Director Date
Once approvals have been obtained. please forward the RFA, blue sheet backup information and originals to City Secretary, Sara White.
ITEMS WILL NOT BE PLACED ON THE COUNCIL AGENDA WITHOUT FINANCE AND LEGAL APPROVAL PRIOR TO SUBMISSION.
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:
*City Attorney signature is required for all items.
REVISED 10/28/2009
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: PW/Engineering and Development
Project Mgr/Resource: Danny Harden
Council Action:
mo
ORDINANCE
Agenda Wording
Project Name: N/A
ContractorNendor: TCEQ
El RESOLUTION
City Manager Approval
CMA Wording
Consider executing "Notice of Change Form" to amend the City's Storm Water Management Program with TCEQ.
Attorney Approval
Z.
Attorney
Notes/Comments