CM-10-01-018Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
James R. Nuse, P.E.
Print Name
City Manager
Title - Owner/President/Other
of City of Round Rock
Corporation/Partnership/Entity Name
have authorized B. Rvan Bell, P.E.
Print Name of Agent/Engineer
of K Friese & Associates, 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 Commission on
Environmental Quality (TCEQ) for the review and approval consideration of regulated
activities.
I also understand that:
1. The applicant is responsible for compliance with 30 Texas Administrative Code
Chapter 213 and any condition of the TCEQ's approval letter. The TCEQ is authorized
to assess administrative penalties of up to $10,000 per day per violation.
2. For applicants who are not the property owner, but who have the right to control and
possess the property, additional authorization is required from the owner.
3. Application fees are due and payable at the time the application is submitted. The
application fee must be sent to the TCEQ cashier or to the appropriate regional office.
The application will not be considered until the correct fee is received by the
commission.
TCEQ-0599 (Rev.10/01 /04) Page 1 of 2
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4. A notarized copy of the Agent Authorization Form must be provided for the person
preparing the application, and this form must accompany the completed application.
I -15-10
A • • li ant's Signature Date
iatt ktu.St., P.L., eilA2
THE STATE OF Texas §
County of VUi! IGm §
BEFORE ME, the undersigned authority, on this day personally appeared SK(ecar--I-. KikStsknown
to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to
me that (s)he executed same for the purpose and consideration therein expressed.
GIVEN under my hand and seal of office on this 17 day of 1'i 0 .
al*:1
SARA L WHITE
MY COMMISSION EXPIRES
July 11, 2012
NOTARY PUBLIC
WA
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: alb (1, uJIZ
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TCEQ-0599 (Rev.10/01/04) Page 2 of 2
Texas Commission on Environmental Quality
Edwards Aquifer Protection Program
Application Fee Form
NAME OF PROPOSED REGULATED ENTITY: Chisholm Trail Reconstruction — Phase 1
REGULATED ENTITY LOCATION: Round Rock, Texas
NAME OF CUSTOMER: City of Round Rock — Department of Utilities
CONTACT PERSON: Don Rundell, P.E. PHONE: (512) 671-2755
(Please Print)
Customer Reference Number (if issued): CN 600413181 (nine digits)
Regulated Entity Reference Number(if issued): RN (nine digits)
Austin Regional Office (3373) ❑ Hays ❑ Travis ® Williamson
San Antonio Regional Office (3362) ❑ Bexar ❑ Comal ❑ Medina ❑ Kinney ❑ Uvalde
Application fees must be paid by check, certified check, or money order, payable to the Texas Commission on
Environmental Quality. 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):
Austin Regional Office
❑ Mailed to TCEQ:
TCEQ — Cashier
Revenues Section
Mail Code 214
P.O. Box 13088
Austin, TX 78711-3088
❑ San Antonio Regional Office
❑ Overnight Delivery to TCEQ:
TCEQ - Cashier
12100 Park 35 Circle
Building A, 3rd Floor
Austin, TX 78753
512/239-0347
Site Location (Check All That Apply): ® Recharge Zone ❑ Contributing Zone
❑ Transition Zone
Water Pollution Abatement Plan, Contributing Zone
Plan: One Single Family Residential Dwelling
Acres $
Water Pollution Abatement Plan, Contributing Zone
Plan: Multiple Single Family Residential and Parks
Acres $
Water Pollution Abatement Plan, Contributing Zone
Plan: Non-residential
Acres $
Sewage Collection System
1,771.06 L.F. $
886.00
Lift Stations without sewer lines
Acres $
Underground or Aboveground Storage Tank Facility
Tanks $
Piping System(s)(only)
Each $
Exception
Each $
Extension of Time
Each $
S i3_c2l/
Signature
21 Dec, 09
Date
If you have questions on how to fill out this form or about the Edwards Aquifer protection program, please contact us at 210/490-
3096 for projects located in the San Antonio Region or 512/339-2929 for projects located in the Austin Region.
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.
TCEQ-0574 (Rev. 4/25/08) Page 1 of 2
WJOJ edea 2103
Texas Commission on Environmental Quality
Edwards Aquifer Protection Program
Application Fee Schedule
30 TAC Chapter 213 (effective 05/01/2008)
Water Pollution Abatement Plans and Modifications
Contributing Zone Plans and Modifications
PROJECT
PROJECT AREA IN ACRES
FEE
One Single Family Residential Dwelling
<
5
$650
Multiple Single Family Residential and Parks
<
5
$1,500
5 <
10
$3,000
10 <
40
$4,000
40 <
100
$6,500
100 <
500
$8,000
>_
500
$10,000
Non-residential (Commercial, industrial, institutional,
multi -family residential, schools, and other sites where
<
1 <
1
5
$3,000
$4,000
regulated activities will occur)
5 <
10
$5,000
10 <
40
$6,500
40 <
100
$8,000
>_
100
$10,000
Organized Sewage Collection Systems and Modifications
PROJECT
COST PER LINEAR FOOT
MINIMUM FEE
MAXIMUM FEE
Sewage Collection Systems
$0.50
$650 - $6,500
Underground and Aboveground Storage Tank System Facility Plans and Modifications
PROJECT
COST PER TANK OR PIPING
SYSTEM
MINIMUM FEE
MAXIMUM FEE
Underground and Aboveground Storage Tank Facility
$650
$650 - $6,500
Exception Requests
PROJECT
FEE
Exception Request
$500
Extension of Time Requests
PROJECT
FEE
Extension of Time Request
$150
TCEQ-0574 (Rev. 4/25/08)
Page 2 of 2
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TCEO
TCEQ Core Data Form
For detailed instructions regarding completion of this form, please read the Core Data Form Instructions or call 512-239-5175.
SECTION I: General Information
1. Reason
for Submission (If other is checked please describe in space provided)
New Permit, Registration or Authorization (Core Data Form should be submitted with the program application)
►1
❑
Renewal (Core Data Form should be submitted with the renewal form)
❑ Other
2. Attachments Describe Any Attachments: (ex. Title V Application, Waste Transporter Application, etc.)
7. General Customer Information
Organized Sewage Collection System Plan
Yes No
3. Customer Reference Number (if issued)
Follow this link to search
❑ Corporation
4. Regulated Entity Reference Number (if issued)
CN 600413181
for CN or RN numbers in
RN
Central Registry**
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mm/dd/yyyy)
// New Regulated Entity ❑ Update to Regulated Entity Name ❑ Update to Regulated Entity Information ❑ No Change** (See below)
**If "NO CHANGE" is checked and Section I is complete, skip to Section IV, Preparer Information.
6. Customer Role (Proposed or Actual) - as it relates to the Regulated Entity listed on this form. Please check only one of the following:
❑Owner ❑ Operator
❑Occupational Licensee ❑ Responsible Party
//
❑
Owner & Operator
Voluntary Cleanup Applicant ❑Other:
7. General Customer Information
❑ New Customer ❑ Update to Customer Information ❑
Change in Legal Name (Verifiable with the Texas Secretary of State) ,
Change in Regulated Entity Ownership
No Change**
**If "No Change" and Section 1 is complete, skip to Section 111- Regulated Entity Information.
8. Type of Customer:
❑ Corporation
❑ Individual
❑ Sole Proprietorship- D.B.A
❑ City Government
❑ County Government
❑ Federal Government
❑ State Government
❑ Other Government
❑ General Partnership
❑ Limited Partnership
❑ Other:
If new Customer, enter previous Customer End Date:
9. Customer Legal Name (If an individual, print last name first: ex: Doe, John) below
10. Mailing
Address:
City
State
ZIP
ZIP + 4
11. Country Mailing Information (if outside USA)
12. E -Mail Address (if applicable)
13. Telephone Number
( ) -
14. Extension or Code 15. Fax Number (if applicable)
I 1( ) -
16. Federal Tax ID (9 digits)
17. TX State Franchise Tax ID (11 digits)
1
18. DUNS Number(ifapplicable)
1
19. TX SOS Filing Number (if applicable)
1
20. Number of Employees
❑ 0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ❑ 501 and higher
21. Independently Owned and Operated?
I ❑ Yes ❑ No
ECTION III: Regulated Entity Information
22. General Regulated Entity Information (If 'New Regulated Entity" is selected below this form should be accompanied by a permit application)
// New Regulated Entity ❑ Update to Regulated Entity Name ❑ Update to Regulated Entity Information ❑ No Change** (See below)
**If "NO CHANGE" is checked and Section I is complete, skip to Section IV, Preparer Information.
23. Regulated Entity Name (name of the site where the regulated action is taking place)
Chisholm Trail Reconstruction - Phase 1
TCEQ-10400 (09/07)
Page 1 of 2
24. Street Address
of the Regulated
Entity:
(No P.O. Boxes)
N/A
36. Nearest City County State Nearest ZIP Code
City
Williamson
State
78664
ZIP
30.5305
ZIP + 4
97.6930
Degrees
25. Mailing
Address:
212 Commerce Blvd
Degrees
Minutes
Seconds
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
•
26. E -Mail Address:
N/A
27. Telephone Number 28. Extension or Code 29. Fax Number (if applicable)
( 512) 671-2755
Sludge
( 512) 218-3242
30. Primary SIC Code (4 digits) 31. Secondary SIC Code (4 digits) 32. Primary NAICS Code 33. Secondary NAICS Code
(5 or 6 digits) (5 or 6 digits)
4952
221320
34. What is the Primary Business of this entity? (Please do not repeat the SIC or NAICS description.)
Wastewater Collection System
-37 address geographic location. Please refer to the instructions for applicability.
35. Description to
Physical Location:
Wastewater main is located in easternmost northbound lane of Chisholm Trail Road from
Chisholm Parkway to approximately 1,450 south of FM 3406.
36. Nearest City County State Nearest ZIP Code
Round Rock
Williamson
TX
78664
37. Latitude (N) In Decimal:
30.5305
38. Longitude (W) In Decimal:
97.6930
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
30
31
49.8
97
41
34.8
39. TCEQ Programs and ID Numbers Check all Programs and write in the permits/registration numbers that will be affected by the updates submitted on this form or the
updates may not be made. If your Program is not listed, check other and write it in. See the Core Data Form instructions for additional guidance.
•
Dam Safety
•
Districts
■
Edwards Aquifer
■
Industrial Hazardous Waste
■
Municipal Solid Waste
1-15---010
■
New Source Review - Air
■
OSSF
•
Petroleum Storage Tank
■
PWS
■
Sludge
■
Stormwater
■
Title V - Air
•
Tires
1
Used Oil
■
Utilities
•
Voluntary Cleanup
►1
Waste Water
•
Wastewater Agriculture
1
Water Rights
■
Other:
SECTION IV: Preparer Information
40. Name:
B. Ryan Bell, P.E.
41. Title:
Project Engineer
42. Telephone Number 43. Ext./Code
( 512) 338-1704
44. Fax Number 45. E -Mail Address
( 512) 338-1487
rbell@kfriese.com
SECTION V: Authorized Signature
46. By my signature below, I certify, to the best of my knowledge, that the information provided in this form is true and complete,
and that I have signature authority to submit this form on behalf of the entity specified in Section II, Field 9 and/or as required for the
updates to the ID numbers identified in field 39.
See the Core Data Form instructions for more information on who should sign this form.)
Company:
City of Round Rock
Job Title:,
K.
Name(!n Print) :
Ja paS iz. 14u5Q,, j>, E ,
hone:
(St. )�l�- 51+1O
Signature:
i
-,„‘„),e0._,./.---...._-,Date:
1-15---010
TCEQ-10400 (09/07)
Page 2 of 2
DATE: January 13, 2010
SUBJECT: City Manager Approval —January 15, 2010
ITEM: Consider executing Organized Sewage Collection Application Chisholm Trail Road
Reconstruction — Phase 1.
Department: Transportation Services
Staff Person: Thomas E. Word, P.E., Chief of Public Works Operations
Justification:
The City of Round Rock plans to reconstruct the existing Chisholm Trail Road from Sam Bass
Road to FM 3406 and to construct the proposed Chisholm Parkway from its existing western
terminus to Chisholm Trail Road. As part of the roadway construction project, the City will
install an 8 -inch wastewater main to provide service for one presently unserved lot.
The wastewater main will connect to an existing manhole on the City's wastewater connection
system located at the intersection of Chisholm Trail Road and Chisholm Parkway. The
alignment will continue northward, located in the center of the easternmost northbound lane
for a distance of approximately 1,770 linear feet where it will terminate with a proposed
manhole location approximately 1,450 feet south of the intersection with FM 3406.
The piping for the project will be constructed by open trench method for the entire alignment.
The trench detail and manhole detail will be per City of Round Rock standards.
Strategic Plan Relevance:
26.0 Construct major elements of the transportation and mobility system as approved by
Council in the Master Transportation Plan
Funding:
Cost: $886.00
Source of funds: 2002 General Obligation Bonds
Outside Resources (if applicable):
TCEQ
Rodriquez Transportation Group
Public Comment (if applicable):
N/A
UPDATED APRIL 2008
10.19 09
Request for City Council/City Manager Action
ILO City Council] City Manager
Submit completed form for all City Manager and City Council approval&
Department Name: Transportation Services
Contact Person: Chaz Gordon / Kathy Michna
Project Mgr/Resource: Bill Stablein
Project Coordinator. Tom Word
Assigned Attorney: Stephan Sheets
City Council or City Manager Approval Date:
Agenda Wording
Project Name: OSCA Application - Chisholm Trail Parkway
Contrac torNendor;
Funding Source: 2002 General Obligation Bonds
Additional funding Source:
Amount $
Account Number
1/18/2010
886.00
Consider executing Organized Sewage Collection Application Chisholm Trail Road Reconstruction - Phase 1.
Finance Information
Is Funding Required?
Initial Construction Contract
Construction Contract Amendment
Change Order
Change in Quantity
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Yes 0 No
Unforeseen Circumstances
Other (Please clearly identify action below)
OSCA application
Amount
S
886.00
N/A Approved
El
[:=1
as
0
Finance/CIP
Finance/Acct
Purchasing
Budget
Date
Date
Date
Date
APPROVALS
(to be Completed ONLY by Finance)
Approved
Finance Director
Odce approvals�.have beenobtained. pease forward the RFA blue sheet. '
back: p rtwmat<on andoriginals to City S'ecretaty, Sara White.
WILL. ITEMS ILL NOT ..E PLACED ON j- i
� �, :. + ;N:'N... AND .APPROVAL «s. PRlfi}N TO SUBMISSION..
Required for Submission of ALL City Council and City Manager items
Project Mgr. Signature:
Dept. Director Signature:
*City Attorney Signatur
City Manager Signature:
Date
Date:
Date:
Date:
Date:
1-6-1c5
145-10
*City Attorney signature is required for ail items.
REVISED 1/512010
10 19 09
Request for City CounciUCity Manager Action
® City Council ED City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Transportation Services
Contact Person: Chaz Gordon / Kathy Michna
Project Mgr/Resource: Bill Stablein
Project Coordinator: Tom Word
Assigned Attorney: Stephan Sheets
City Council or City Manager Approval Date:
Agenda Wording
For Administration Use ONLY
Received:
Tag #:
Original Documents Received:
Project Name: OSCA Application - Chisholm Trail Parkway
Contractor/Vendor:
Funding Source: 2002 General Obligation Bonds
Additional funding Source:
Amount: $
Account Number:
1/18/2010
886.00
Consider executing Organized Sewage Collection Application Chisholm Trail Road Reconstruction - Phase 1.
Finance Information
0
Is Funding Required?
Yes n No n
Initial Construction Contract
Construction Contract Amendment
Change Order #
=Change in Quantity EUnforeseen Circumstances
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Other (Please clearly identify action below)
OSCA application
Amount
$ 886.00
FINANCE
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
WA Approved
QFinance/CIP L Olsen Date 1/12/2010
CIED Finance/Acct E. Wilson Date 1/13/2010
iia Purchasing EE Bowden Date 1/12/2010
EDED Budget P. Bryan Date 1/12/2010
Ix
Approved
Cheryl Delaney
1/13/2010
Finance Director Date
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.
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 1/13/2010
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: PUBLIC WORKS
Project Mgr/Resource: TOM WORD
Council Action:
ORDINANCE
Agenda Wording
OSCA APPLICATION - CHISHOLM TRAIL
Project Name: PARKWAY
Contractor/Vendor:
ni RESOLUTION
City Manager Approval
CMA Wording
Consider executing Organized Sewage Collection Application Chisholm Trail Road Reconstruction - Phase 1.
Attorney Approval
DAttorney
Notes/Comments
Date <?/
1.0
O:\wdox\SCCInts\0125\0902\M ISC\00179496
Updated 6/3/08