CM-10-08-158Logi
TCEQ
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)'
Renewal (Core Data Form should be submitted with the renewal form)
® Other
Recharge Zone Exception
2. Attachments Describe Any Attachments: (ex. Title V Application, Waste Transpo terApplication, etc.)
®Yes ❑No
3. Customer Reference Number (if issued)
CN 600413181
SECTION II: Customer Information
Follow this Zink to search
for CN or RN numbers in
Central Registry**
4. Regulated Entity Reference Number (if issued)
RN
5. Effective Date for Customer Information Updates (mm/dd/yyyy)
0 New Regulated Entity ❑ Update to Regulated Entity Name ❑ Update to Regulated Entity 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:
❑Owner ❑ Operator
❑Occupational Licensee ❑ Responsible Party
E
❑
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)
❑
F
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 Govemment
❑ Other Government
❑ General Partnership
❑ Limited Partnership
❑ Other:
9. Customer Le !f new Customer, enter previous Customer
Legal Name If an individual, last name Doe,
(
g print first ex: John ) End Date:
below
10. Mailing
Address:
City
State
ZIP
ZIP + 4
11. Country Mailing Information (ifoutside USA)
12. E -Mail Address (if applicable)
13. Telephone Number
( ) -
14. Extension or Code 15. Fax Number (if applicable)
1 1( ) -
16. Federal Tax ID (9 digits)
17. TX State Franchise Tax ID (t/ digits)
I I
18. DUNS Numberf►reppiicable)
19. TX SOS Filing Number (if applicable)
20. Number of Employees
❑ 0-20 ❑ 21-100 ❑ 101-250 ❑ 251-500 ❑ 501 and higher
21. Independently Owned and; Operated?
I ❑ 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)
0 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)
Round Rock City Hall Campus Improvements
TCEQ-10400 (09/07)
Page 1 of 2
24. Street Address
of the Regulated
Entity:
(No P.O. Boxes)
City of Round Rock
212 E. Main S t .
City
Round Rock
State
TX
Zip
78664
ZIP + 4
Degrees
25. Mailing
Address:
City of Round Rock
Degrees
301 W. Bagdad, Ste. 250
Seconds
City
Round Rock
State
TX
Zip
78664
ZIP + 4
•
26. E -Mail Address:
dbuzzell@round-rock.tx.us
27. Telephone Number 28, Extension or Code 29: Fax Number (if applicable)
(512)341.. 3345
Sludge
(512 )218. 5548
30. Primary SIC Code (4 digits) 31. Secondary SIC Code (4 digits) 32. Primary NAICS Code 33. SecondaryNAICS Code
(5 or 6 digits) (5 or 6 dt}
34. What is the Primary Business of this entity? (Please do not repeat the SIC or NAILS description.)
Pedestrian
Questions 34 - 37 address geographic location
35. Description to
p
Physical Location:
North on IH 35 from Austin, exit Hwy. 620. Turn right on Round
Rock Ave. Continue past N. Mays until you get to the
intersection of E. Main St. and Sheppard St.
36. Nearest City County State Nearest ZIP Code
Round Rock
Williamson
TX
78664
37. Latitude (N) In Decimal:
•
38. Longitude (W) In Decimal:
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
30
30
31.1898
-97
40
36.8436
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
Fro
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
■
Waste Water
■
Wastewater Agriculture
■
Water Rights
1
Other:
SECTION IV: Preparer Information
40. Name:
David Buzzell, RLA, ASLA
41. Title:
Parks Project Manager
42. Telephone Number 43. Ext./Code 44. Fax Number 45: E -Mail Address
(512)3413345
(512)218 5548
dbuzzell@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 this form.)
Company:
Nameon Print)
Signature:
TCEQ-10400 (09/07)
£i4 -j oQt2ou "Rock
Me_s R, f 1U Se, P.E.
Job Title:
Phone:
Phone:
Date: S4-10
Page 2 of 2
Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
Jim Nuse, P.E.
Print Name
City Manager
Title - Owner/President/Other
of City of Round Rock
Corporation/Partnership/Entity Name
have authorized David Buzzell, RLA, ASLA
Print Name of Agent/Engineer
of City of Round Rock - PARD
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 those submitting an application 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.
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.
5. No person shall commence any regulated activity on the Edwards Aquifer Recharge
Zone, Contributing Zone or Transition Zone until the appropriate application for the
activity has been filed with and approved by the Executive Director.
TCEQ-0599 (Rev.04/01 /2010) Page 1 of 2
SIGNATURE PAGE:
%41640
nt's Signature Date
THE STATE OF � §
County of tA) i f'I £h45K §
BEFORE ME, the undersigned authority, on this daypersonally appeared 11/4-6-Y p Y ppknown
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 day of
,z_for2
• ��i� .Ma-4tir
NOTARY UBLI
Iota Iv((1 6-. kopcm&
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: 4-1 b rZv (
TCEQ-0599 (Rev.04/01/2010) Page 2 of 2
ROUND ROCK, TEXAS
PURPOSE, PASSION. PROSPERITY.
Item Caption:
Approval Date:
Ci Mana; er A • • royal Summar Sheet
Consider executing "Agent Authorization Form for Required Signature Edwards Aquifer
Protection Program Relating to 30 TAC Chapter 213" authorizing David Buzzell to
represent and act on behalf of the City regarding the City Hall Campus Project.
August 6, 2010
Department: Parks and Recreation
Project Manager: David Buzzell, RLA, ASLA
Item Summary:
The City Hall Campus Improvements Project falls under the Edwards Aquifer Protection Program. Based on the
minimal increase in impervious cover and the vegetated buffer strip that exists on site, the City is submitting an
Exception Request to the Texas Commission on Environmental Quality.
Strategic Plan Relevance:
Cost: $ 500.00
Source of Funds: 2002 GO Bonds
REV. 6/10/10