CM-12-04-059O'H2'e1-1_0
Sy
RECEIVED
PR 0 4 2012
City Manager Approval Form
MOON Pterearn
Item Caption:
Consider executing TCEQ forms (1) "Agent Authorization Form For Required Signature Edwards Aquifer
Protection Program Relating to 30 TAC Chapter 213" authorizing Jason Roberts to represent and act on behalf
of the City, and (2) TCEQ Core Data Form regarding the Lake Creek 2 Wastewater Improvements Project.
Approval Date: April 6, 2012
Department Name: Utilities and Environmental Services Department
Project Manager: Eddie Zapata
Assigned Attorney:
Steve Sheets
Item Summary:
The Lake Creek 2 Wastewater Improvements Project consists of upsizing and consolidating two Targe wastewater lines running in
and along the Lake Creek channel roughly from Mays Street going east over to Lake Creek Park (near the City's Dog Park). The line
is located over the Edwards Aquifer Recharge Zone (EARZ) and as a result, the City must address the EARZ requirements. This
includes execution of the Agent Authorization form to authorize Jason Roberts, P.E. of Bury and Partners to act as an agent to the
City for this project. This will allow the engineers to submit the application for approval of an Organized Sewer Collection System
(SCS) for these new lines.
No. of Originals Submitted: 2
Project Name: Lake Creek 2 Wastewater Line Upgrade
Cost: Not Applicable
Source of Funds: Select Source Fund
Source of Funds (if applicable): Select Source Fund
Account Number: WW02LKCRK2
Finance Director Approval: L.O. for Cheryl Delaney
Date: 4-4-12
Department Director Approval: Michael Thane Date: 4/2/12
**Electronic signature by the Director is acceptable. Please only submit ONE approval form per item. **
CIP Budget n Purchasing Z El Accounting n
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
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
Renewal (Com Data Form should be submitted with the renewal form)
Yes ❑No SCS Application
RN 100822600
SECTION II: Customer Information
5. Effective Date for Customer Information Updates (mmlddlyyyy)
®Owner ❑ Operator
['Occupational Licensee ❑ Responsible Party
❑ Owner & Operator
❑ Voluntary Cleanup Applicant Daher:
❑ New Customer ❑ Update to Customer Information ❑ Change in Regulated Entity Ownership
['Change in Legal Name (Verifiable with the Texas Secretary of State) ® No Change"
*Mf "No Change" and Section 1 is complete. skip to Section 111— Regulated Entity Information.
❑ Corporation
❑ Individual
® City Govemment
❑ County Govemment
0 Sole Proprietorship- D.B.A
0 Federal Govemment ❑ State Govemment
❑ Other Govemment
0 General Partnership
❑ Limited Partnership ❑ Other:
State
ZIP
ZIP +4
0-20 ❑ 21-100 0 101-250 0 251-500 0 501 and higher
SECTION III: Regulated Entity Information
Yes
No
is f .
New Regulated Entity ❑ Update to Regulated Entity Name 0 Update to Regulated Entity Information
❑ No Change** (see below)
"If "N0 CHANGE" is checked and Section I is complete, skip to Section IV, Preparer Information.
TCEQ-10400 (09/07)
NIA -tZ—ee.1— o s1
Page 1 of 2
2008 Enterprise Drive
Round Rock
State
TX
ZIP
78664
ZIP +4
2008 Enterprise Drive
Round Rock
State
TX
ZIP
78664
ZIP +4
dfreireich • roundrocktexas..ov
( 512 ) 671-2756
4952
( 512 ) 218-3242
221320
Municipality
Questions 34 — 37 address , : • , ra • hic location. Please refer to the instructions for a ' ' Iicabili
S. Mays Street (just south of Lake Creek going east over to Lake Creek Park)
Round Rock
Williamson
78664
Minutes
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
►Zi
Edwards Aquifer
•
Industrial Hazardous Waste
•
Municipal Solid Waste
•
New Source Review - Air
•
OSSF
•
Petroleum Storage Tank
■
PWS
■
Sludge
•
Stormwater
IN
Title V - Air
IN
Tires
•
Used Oil
■
Utilities
•
Voluntary Cleanup
0
Waste Water
•
Wastewater Agriculture
•
Water Rights
■
Other:
SECTION IV: Preparer Information
( 512 ) 671-2756
(512) 218-3242
Senior Utility En weer
dfreireich@roundrocktexas.gov
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 (09/07)
Page 2 of 2
Agent Authorization Form
For Required Signature
Edwards Aquifer Protection Program
Relating to 30 TAC Chapter 213
Effective June 1, 1999
I Steve Norwood
Print Name
City Manager
Title - Owner/President/Other
of City of Round Rock, Texas
Corporation/Partnership/Entity Name
have authorized Jason Roberts, P.E.
Print Name of Agent/Engineer
of Bury+Partners
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
Cm -(2 -ori -0 S?
SIGNATURE PAGE:
Applicant's Signature Date
THESTATEOFTS §
County of W! 1 I §
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, anc 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 'qday of • t
SINN& . 146eck
NOTARY PUBLIC
Snvd,Ihile
Typed or Printed Name of Notary
MY COMMISSION EXPIRES: 0.14, I(I%la,
TCEQ-0599 (Rev.04/01/2010) Page 2 of 2