CM-11-10-217ROUND ROCK, TEXAS
C11?o 'Q,PI'RECEIVEO
OCT 262011
City Manager Approval Form
Consider executing "Agent Authorization Form For Required signature Edwards Aquifer Protection Relating to 30 TAC
Chapter 213" authorizing B. Ryan Bell to represent and act on behalf of the City regarding the Chisholm Trail Road
Item Caption: ReronetyurtiOP/PariDuzy EvtPnciors Projart
Approval Date:
October 28, 2011
Department Name:
Transportation Department
Project Manager.
Bill Stablein
Assigned Attorney:
Steve Sheets
Item Summary:
For the ChisholmTrail Road Reconstruction/Parkway Extension project, Chisholm Trail Road will be reconstructed to a five -lane
urban section and Chisholm Parkway will be extended from its current termini to Chisholm Trail Road.
This agent authorization form needs City Manager approval so that the City Manager may represent and act on the behalf of the
City of Round Rock for the purpose of preparing and submitting this plan application to the Texas Commission on Environmental
Quality (TCEQ) for the review and approval of considered regulated activities.
No. of Originals Submitted: Two
Project Name: Chisholm Trail Road Reconstruction/Parkway Exension
Cost: None
Source of Funds: Select Source Fund
Source of Funds (if applicable): Select Source Fund
Account Number.
Finance Director Approval: Cheryl Delaney Date: 10/26/11
Department Director Approval: Gary Hudder Date: 10/28/11
**Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. **
CIP LI n Budget 1 1 Purchasing Ell Accounting LI
N/A OK N/A OK N/A OK N/A OK
ITEMS WILL NOT BE PLACED ON THE COUNCIL OR CM AGENDA W/OUT PRIOR FINANCE AND/OR LEGAL APPROVAL
REV. 6/20/11
Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
Steve Norwood
Print Name
City Manager
Title - Owner/President/Other
of City of Round Rock
Corporation/Partnership/Entity Name
have authorized B. Ryan Bell, P.E.
Print Name of Agent/Engineer
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 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
t 1—lb —'Lr+
SIGNATURE PAGE:
Applicant's Signature Date
THE STATE OFT% S §
County of WLlI i4MSel §
BEFORE ME, the undersigned authority, on this day personally appeared <3k'V� kia11424 known
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 , 204
,ARALwt:1�E
MY CC t4ISSIONEXPIRES
$ „11,2012
ciintit,. kebob?
NOTARY PUBLIC
Sari L. 1Ani+e)
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: II12,012—.
TCEQ-0599 (Rev.04/01/2010) Page 2 of 2
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)
2. Attachments Describe Any Attachments: (ex. Title V Application, Waste Transporter Application, etc.)
0 Other
®Yes ❑No
Organized Sewage Collection System Plan
3. Customer Reference Number (if issued)
CN 600413181
SECTION II: Customer Information
Follow this link 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 (mmlddlyyyy)
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)
❑
►ZI
Change in Regulated Entity Ownership
No Chan •e**
"If "No Change" and Section I is complete, skip to Section 111- Regulated Entity Information.
8. Type of Customer:
❑ Corporation
❑ Individual
❑ Sole Proprietorship- D.B.A
❑ City Govemment
❑ County Govemment
❑ Federal Govemment
❑ State Government
❑ Other Govemment
❑ General Partnership
❑ Limited Partnership
❑ Other:
9. Customer Legal Name (If an individual, print last name firstex: Doe, John) If new Customer, enter previous Customer
below End Date:
10. Mailing
Address:
City
State
ZIP
ZIP + 4
11. Country Mailing Information (if outside usA)
12. E -Mail Address (if applicable)
13. Telephone Number
( ) - 1
14. Extension or Code 15. Fax Number (if applicable)
I(
16. Federal Tax ID (9 digits)
17. TX State Franchise Tax ID (11 digits)
18. DUNS Numberoiapplicade)
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?
1 ❑ 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)
Chisholm Trail Reconstruction - Phase 1A
TCEQ-10400 (09/07)
Page 1 of 2
24. Street Address
of the Regulated
Entity:
No P.O. Boxed
N/A
City I I State 1
25. Mailing
Address:
2008 Enterprise Dr.
1 ZIP I I ZIP + 4 1
City
Round Rock
State
TX
ZIP
78664
ZIP +4
26. E -Mail Address:
27. Telephone Number
N/A
( 512) 671-2755
28. Extension or Code 29. Fax Number (if applicable)
( 512 ) 218-3242
30. Primary SIC Code (4 digits) 31. Secondary SIC Code (4 digits)32. Primary NAICS Code
(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
33. Secondary NAICS Code
(5 or 6 digits)
Questions 34 —37 address geographic location• Please refe to the tt
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. Seethe Core Data Form instructions for additional 'd
r ns racoons for appllcaoiiiry.
35. Description to
Physical Location:
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
Industrial Hazardous Waste
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. Seethe Core Data Form instructions for additional 'd
SECTION IV: Preparer Information
40. Name:
B. Ryan Bell, P.E.
41. Title:
42. Telephone Number 43. Ext./Code
Project Engineer
44. Fax Number 45. E -Mail Address
( 512) 338-1704
(512)338-1487
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.)
rbell@kfriese.com
Company:
Namepn Roo:
Signature:
TCEQ-10400 (09/07)
City of Round Rock
Job Title:
Gr ' -t IVV'ia 9-er
Phone:
Date:
(S12 71f Sy( a
;i;/;�
Page 2 of 2
gm ante.
•
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
0
Waste Water
■
Wastewater Agriculture
Water Rights
■
■
Other.
SECTION IV: Preparer Information
40. Name:
B. Ryan Bell, P.E.
41. Title:
42. Telephone Number 43. Ext./Code
Project Engineer
44. Fax Number 45. E -Mail Address
( 512) 338-1704
(512)338-1487
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.)
rbell@kfriese.com
Company:
Namepn Roo:
Signature:
TCEQ-10400 (09/07)
City of Round Rock
Job Title:
Gr ' -t IVV'ia 9-er
Phone:
Date:
(S12 71f Sy( a
;i;/;�
Page 2 of 2