CM-10-02-042umam
TCEQ
TCEQ Core Data Form
TCEQ Use Only
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
New Permit, Registration or Authorization (Core Data
describe in space provided)
Form should be submitted with the program application)
❑
Renewal (Core Data Form should be submitted with
the renewal form) /1 Other Change of Ownership
2. Attachments
Describe Any Attachments: (ex. Title VApplication, Waste Transporter Application, etc.)
❑ New Customer ❑ Update to Customer Information
Change in Legal Name (Verifiable with the Texas Secretary of State)
11Yes No
Permit Application - West Plant
**If "No Change" and Section 1 is complete, skip to Section III— Regulated Entity Information.
3. Customer Reference Number (if issued)
Follow this link to search
4. Regulated Entity Reference Number (if issued)
CN 600413181
for CN or RN numbers in
RN 100822592
Central Registry*
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
12/8/2009
Information ❑ No Change** (See below)
6. Customer Role (Proposed or Actual) — as it relates to the Regulated Entity listed on this form. Please check only one of the following:
23. Regulated Entity Name (name of the site where the regulated action is taking place)
Brushy Creek Regional Wastewater Plant
Owner ❑ Operator ❑ Owner & Operator
Occupational Licensee ❑ Responsible Party ❑ 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)
.1
❑
Change in Regulated Entity Ownership
No Change**
**If "No Change" and Section 1 is complete, skip to Section III— Regulated Entity Information.
8. Type of Customer:
❑ Corporation
❑ Individual
❑ Sole Proprietorship- D.B.A
/t
City Government
❑ County Government
❑ Federal Government
❑ State Government
❑ Other Government
❑ General Partnership
❑ Limited Partnership
❑ Other:
9. Customer Legal Name (If an individual, last name first: Doe, John) If new Customer, enter previous Customer
print ex: End Date:
below
City of Round Rock
10. Mailing
Address:
City of Round Rock
221 E Main St.
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
11. Country Mailing Information (if outside USA)
12. E -Mail Address (if applicable)
N/A
mthane@round-rock.tx.us
13. Telephone Number
( 512 ) 218-3236
14. Extension or Code
N/A
15. Fax Number (if applicable)
( 512 ) 218-3242
16. Federal Tax ID (9 digits)
746017485
17. TX State Franchise Tax ID (11 digits)
N/A
18. DUNS Number(aapplicable)
102740792
19. TX SOS Filing Number (if applicable)
N/A
20.
Number of Employees
0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ❑ 501 and higher
21. Independently
I
Owned and Operated?
Yes ❑ No
SECTION 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)
Brushy Creek Regional Wastewater Plant
GM-1&OZ—D
TCEQ-10400 (09/07)
Page 1 of 2
uestions 34 - 37 addr
35. Description to
Physical Location:
24. Street Address
of the Regulated
Entity:
fNo P.O. Boxes)
Brushy Creek Regional Wastewater Plant - West Plant
1116 E. Austin Ave.
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
Degrees
Minutes
25. Mailing
Address:
Degrees
221 E. Main St.
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
New Source Review - Air
26. E -Mail Address:
mthane@round-rock.tx.us
27. Telephone Number 28. Extension or Code 29. Fax Number (if applicable)
(512)218-3236
PWS
(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
N/A
22132
221320
34. What is the Primary Business of this entity? (Please do not repeat the SIC or NAICS description.)
Wastewater Treatment
uestions 34 - 37 addr
35. Description to
Physical Location:
- . -.- --- -------... . ._..__ •...... .v ...... n.aa. Mara.V...l .VI arlr.AltaaYlllty.
East of downtown Round Rock, at dead end of Austin Ave.
36. Nearest City County State Nearest ZIP Code
Round Rock
Williamson
TX
78665
37. Latitude (N) In Decimal:
38. Longitude (W) In Decimal:
•
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
•
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
•
■
•
New Source Review - Air
•
OSSF
•
Petroleum Storage Tank
PWS
Sludge
■
•
•
Stormwater
■
Title V - Air
•
Tires
Used Oil
Utilities
■
•
■
Voluntary Cleanup
it
Waste Water
IN
Wastewater Agriculture
Water Rights
Other:
■
■
SECTION IV: Preparer Information
40. Name:
Michael Thane
41. Title:
Director of Utilities
42. Telephone Number 43. Ext.ICode
44. Fax Number 45. E -Mail Address
( 512) 218-3236
(512) 218-3242
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.)
of Ra.iunztocK.
J cs Wise, E .
mthane@round-rock.tx.us
Company:
Namean Print) :
Signature:
Job Title:
eity\ M
hone: (51SyO�
Date:
TCEQ-10400 (09/07)
R-161-10
Page 2 of 2
DATE: February 17, 2010
SUBJECT: City Manager Approval — February 19, 2010
ITEM: Consider executing TCEQ Core Data Form regarding permit application for the
Brushy Creek Regional Wastewater Plant — West Plant.
Department:
Staff Person:
Water and Wastewater Utilities
Michael Thane, Director of Utilities
Justification:
The Cities of Round Rock, Austin and Cedar Park purchased the Brushy Creek Regional
Wastewater System (BCRWWS) from the LCRA. The system consists of two plants, known as
the East Plant and West Plant. The Cities agreed to fully release and discharge LCRA from any
further obligations or liability related to the BCRWWS. In order to transfer the three cities'
names onto the TCEQ wastewater permits from LCRA, TCEQ requires proper execution of the
core data forms including an executive signature from each City.
The LCRA is writing a letter to TCEQ requesting that their name be removed from both permits.
The Cities of Austin and Cedar Park will likewise submit their Core Data Forms which will
complete the transfer of the wastewater permit to the cities.
Strategic Plan Relevance:
Goal 28.0 "Protect public health and protect the environment through proper waste disposal."
Funding:
Cost: N/A
Source of funds: N/A
Outside Resources (if applicable):
Cities of Austin and Cedar Park
Brazos River Authority
Lower Colorado River Authority
Public Comment (if applicable): N/A
UPDATED: October 19, 2009
10 19
Request for City Council/City Manager Action
® City Council IID City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Water and Wastewater Utilities
Contact Person: Chaz Gordon / Kathy Michna
Project Mgr/Resource:
Project Coordinator: Michael Thane
Assigned Attorney: Steve Sheets
City Council or City Manager Approval Date:
Agenda Wording
ELEIVEfi
For Administration Use ONLY
EB 1 7 2010
T> 'YY1- r0- D z -04 Z,
Original Documents Received:
Project Name: Brushy Creek Regional Wastewater System
Contractor/Vendor: Texas Commission on Environmental Quality
Funding Source:
Additional funding Source: N/A
Amount N/A
Account Number: N/A
2/19/2010
Consider executing TCEQ Core Data Form regarding permit application for the Brushy Creek Regional Wastewater Plant - West Plant.
Finance Information
0
cJ
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 10 I No n
Unforeseen Circumstances
Other (Please clearly identify action below)
Amount
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
FINANCE
WA Approved
El Finance/CIP Date
QEJ Finance/Acct Date
QED Purchasing Date
0 Budget Date
Finance Director
Once approvals have been obtained, please forward the RFA, blue sheet, hack op information and oripmals 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:
Dept. Director Signature:
'City Attomey Signature:
City Manager Signature:
Date
Date:
Date:
Date
Date
2 -19 -CO
2—(61-1 0
'City Attorney signature is required for alt items.
REVISED 2/17/2010
10 19 09
Request for City Council/City Manager Action
® City Council ED City Manager
Submit completed form for all City Manager and City Council approvals.
Department Name: Water and Wastewater Utilities
Contact Person: Chaz Gordon / Kathy Michna
Project Mgr/Resource:
Project Coordinator:
Assigned Attorney: Steve Sheets
Michael Thane
City Council or City Manager Approval Date:
Agenda Wording
For Administration Use ONLY
Received:
Tag #:
Original Documents Received:
Project Name: Brushy Creek Regional Wastewater System
Contractor/Vendor: Texas Commission on Environmental Quality
Funding Source:
Additional funding Source: N/A
Amount: N/A
Account Number: N/A
2/19/2010
Consider executing TCEQ Core Data Form regarding permit application for the Brushy Creek Regional Wastewater Plant - West Plant.
Finance Information
Is Funding Required? Yes
Initial Construction Contract
Q Construction Contract Amendment u
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
E2
No
Other (Please clearly identify action below)
Amount
FINANCE
N/A Approved
ED ED
Finance/CIP B. ramsey
Finance/Acct E. Wilson
Purchasing EE Bowden
Budget P. Bryan
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
Date 2/17/2010
Date 2/16/2010
Date 2/16/2010
Date 2/16/2010
lX
ESW for C. Delaney 2/17/2010
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 2/17/2010
LEGAL DEPARTMENT APPROVAL FOR CITY COUNCIL/CITY MANAGER ACTION
Required for Submission of ALL City Council and City Manager Items
Department Name: PW/Utilities
Project Mgr/Resource: Michael Thane
Project Name: Brushy Creek Regional Wastewater System
Contractor/Vendor: Texas Commission on Environmental Quality
17Council Action:
ORDINANCE ri RESOLUTION
Agenda Wording
City Manager Approval
CMA Wording
Consider executing TCEQ Core Data Form regarding permit application for the Brushy Creek Regional Wastewater Plant - West
Plant.
Attorney Approval
Attorney
Notes/Comments
Date
Oawdox\SCCtnts10199\0910-GEN\MISC\00182634.XLS
Updated 6/3/08