CM-12-03-041-�Z-o3-o` J RECEIVE
FEB 29 201Z
"1)14.114"..-111":"13CIC TEXAS
City Manager Approval Form
Consider executing TCEQ forms (1) "Agent Authorization Form For Required Signature Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213" authorizing B. Ryan Bell to represent and act on behalf of the City, and (2) TCEQ Core Data
Item : Fere regarding tiler/110,4M tiler/110,4MTran Poad PAconetnrtion/Parkway ivtenKion projeet
Approval Date: March 2,2012
Department Name Transportation Department
project Manager: Bill Stablein
Assigned Attorney: Steve Sheets
Item Summary:
For the Chisholm Trail 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.
The initial permit authorization was approved by the City Manager on October 28, 2011. A permit extension is needed In order
to keep the initial authorization intact. The extension will expire six months after it is approved by the TCEQ. Future extensions
may also be required before enough construction has been completed to keep the permit in place.
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: 2/29/12
Department Director Approval: Gary Hudder Date: 2/27/12
**Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. * *
CIP ❑ Budget El ❑ Purchasing ❑ ❑ Accounting ❑
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
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 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:
Applicant's Signature Date
THE STATE OFr IC1 §
County of jJjLI tAlI 4& 1 §
BEFORE ME, the undersigned authority, on this day personally appeared 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
94444,.d*
NOTARY PUBLIC
' 1LL • tAlliaR
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: 3145 1('2'2--
TCEQ-0599 (Rev.04/01/2010) Page 2 of 2
TCEQ Core Data Form
TCEQ Use
For detailed instructions regarding completion of this form, please read the Core Data Form Instructions or call 512-239-5175.
SECTION I: General Information
® Renewal (Core Data Form should be submitted with the renewal form)
®Yes ❑No Extension Request for Edwards Aquifer Plan
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
❑ Owner 0 Operator
❑ occupational Licensee 0 Responsible Party
® Owner & Operator
❑ Voluntary Cleanup Applicant ❑other:
0 New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership
❑ Change in Legal Name (Verifiable with the Texas Secretary of State) ® No Change"
"If "No Change" and Section l is complete, skip to Section 111— Regulated Entitv Information.
® City Govemment
❑ Corporation
0 Individual
❑ Sole Proprietorship- D.B.A
❑ County Govemment
❑ Federal Govemment
0 State Govemment
0 Other Govemment
❑ General Partnership
❑ Limited Partnership
0 Other:
2008 Enterprise Blvd
City
Round Rock
State
TX
ZIP
78664
ZIP +4
0 0-20 ❑ 21-100 ❑ 101-250 0 251-500 ❑ 501 and higher
SECTION III: Regulated Entity Information
New Regulated Entity 0 Update to Regulated Entity Name ❑ Update to Regulated Entity Information
"If "N0 CHANGE° Is checked and Section I is complete, skip to Section IV, Preparer Information.
TCEQ-10400 (09107)
Page 1 of 2
City
City
(
State ZIP
State
ZIP
(
ZIP +4
ZIP + 4
do
car
)
Questions 34 - 37 address geographic location. Please refer to the instructions for applicability.
iw!
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
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
_
•
New Source Review — Air
•
OSSF
•
Petroleum Storage Tank
■
PWS
•
Sludge
IN
Stomiwater
■
Title V — Air
■
Tires
■
Used Oil
■
Utilities
•
Voluntary Cleanup
■
Waste Water
■
Wastewater Agriculture
•
Water Rights
■
Other:
SECTION IV: Preparer Information
B Ryan Bell, P.E.
41.E
Project Engineer
( 512) 338-1704
(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.)
TCEQ-10400 (09107)
Page 2 of 2
City of Round Rock
ci+ymiula.
tr.
S 2(N°woe d
:
(z!a) 9-5010
_
TCEQ-10400 (09107)
Page 2 of 2