CM-10-02-043lag
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) I Other Change of Ownership
2. Attachments
Describe Any Attachments: (ex. Title V Application, Waste Transporter Application, etc.)
❑ New Customer ❑ Update to Customer Information
❑Change in Legal Name (Verifiable with the Texas Secretary of State)
II Yes No
Permit Application - East Plant
**If "No Change" and Section 1 is complete, skip to Section 111— 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 100822600
Central Registry—
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
12/8/2009
❑ 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)
0Owner
❑Occupational
❑ Operator ❑ Owner & Operator
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 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:
9. Customer Legal Name (If an individual, last first: Doe, John) If new Customer, enter previous Customer
print name ex: End Date:
bel ow
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
0
15. Fax Number (if applicable)
( 512 ) 218-3242
16. Federal Tax ID (9digits)
746017485
17. TX State Franchise Tax ID (11 digits)
N/A
18. DUNS Numberpfapprcabte)
102740792
19. TX SOS Filing Number (if applicable)
N/A
20.
/1
Number of Employees
0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ❑ 501 and higher
21. Independently
A
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
-10-0Z.-o
TCEQ-10400 (09/07)
Page 1 of 2
24. Street Address
of the Regulated
Entity:
fNo P.O. Boxes)
Brushy Creek Regional Wastewater Plant - East Plant
3939 East Palm Valley Blvd.
City
Round Rock
State
TX
ZIP
78665
ZIP + 4
•
Degrees
25. Mailing
Address:
Seconds
221 E. Main St.
City
Round Rock
State
TX
ZIP
78664
ZIP + 4
26. E -Mail Address: mthane@round-rock.tx.us
27. Telephone Number 28. Extension or Code 29. Fax Number (if applicable)
(512)218-3236
(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
Questions 34 - 37 address
35. Description to
Physical Location:
East of IH -35, off of Highway 79
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
Municipal Solid Waste
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.
SECTION IV: Preparer Information
40. Name:
Michael Thane
41. Title:
Director of Utilities
42. Telephone Number 43. Ext./Code
44. Fax Number 45. E -Mail Address
( 512) 218-3236
(512) 218-3242
mthane@round-rock.tx.us
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 th
Company:
, . .
CAf of 'Rolm)'Rolm)'Rolm)7 Job Title: C Aqua
yup
Namee&
(in Print):
�S K. muSC , P �.
Phone:
(512 ) (g - 540 )
Signature:=.
v: �,.�----
\-
•
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
IN
Used Oil
•
Utilities
■
Voluntary Cleanup
i4
Waste Water
•
Wastewater Agriculture
■
Water Rights
•
Other:
SECTION IV: Preparer Information
40. Name:
Michael Thane
41. Title:
Director of Utilities
42. Telephone Number 43. Ext./Code
44. Fax Number 45. E -Mail Address
( 512) 218-3236
(512) 218-3242
mthane@round-rock.tx.us
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 th
Company:
, . .
CAf of 'Rolm)'Rolm)'Rolm)7 Job Title: C Aqua
yup
Namee&
(in Print):
�S K. muSC , P �.
Phone:
(512 ) (g - 540 )
Signature:=.
v: �,.�----
\-
Date:
2-iq-io
TCEQ-10400 (09/07)
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 — East 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 APRIL 2008
101909
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:
Michael Thane
Assigned Attorney: Steve Sheets
City Council or City Manager Approval Date:
Agenda Wording
ECFIVED
For Administration Use ONLY
FEB rf11
1 ED i_ 1, '2010
1.
Received.
m
Ta �:,10-o2- a43
Original Documents Received: 2
Project Name: Brushy Creek Regional Wastewater System
ContractorNendor 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 - East Plant.
Finance Information
Is Funding Required?
Initial Construction Contract
Construction Contract Amendment
Change Order
OChangein Quantity
Initial Professional Services Agreement
Supplemental Professional Service Agreement
Purchasing/Service Agreement
Purchase Order
Item(s) to be purchased
Yes 0 No p
Unforeseen Circumstances
Other (Please clearly identify action below)
Amount
FINANCE
WA Approved
O EJ Finance/CIP Date
ElO Finance/Acct Dake
1Jo Purchasing Date
O ED Budget Date
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
Finance Director
Once appro 319 mace noon obtained please /onward the RFA, blue sheet, back up into /nation 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
Reuuired 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:
2- 11- ID
2-11-10
°City Attorney signature is required for all items.
REVISED 2/17/2010
Request for City Council/City Manager Action
10.19 09
En City Council III] 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 Attomey: 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
ContractorNendor: 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 - East Plant.
Finance Information
EJ
iJ
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 ri No 0
#
=Unforeseen Circumstances
Other (Please clearly identify action below)
Amount
FINANCE
N/A Approved
EJ
CI
0
Finance/CIP B.Ramsey
Finance/Acct E. Wilson
APPROVALS
(to be completed ONLY by Finance)
Final Finance Approval Required
Approved
Date 2/17/2010
Date 2/16/2010
Purchasing EE Bowden Date 2/16/2010
Budget P. Bryan
Date 2/16/2010
Ix
ESW for C. Delaney
Finance Director
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.
2/17/2010
Date
Required for Submission of ALL City Council and City Manager Items
Project Mgr. Signature:
Dept. Director Signature:
*City Attorney Signature:
City Manager Signature:
Date:
Date:
Date:
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
Council Action:
ORDINANCE
Agenda Wording
Project Name: Brushy Creek Regional Wastewater System
COntractorNendOr: Texas Commission on Environmental Quality
ri RESOLUTION
City Manager Approval
CMA Wording
Consider executing TCEQ Core Data Form regarding permit application for the Brushy Creek Regional Wastewater Plant - East
Plant.
Attorney Approval
Attorney
Date
Notes/Comments
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Updated 6/3/08