HomeMy WebLinkAboutTCEQ':_:; Notice of Intent (NOi) for Storm Water TCEQ Office Use Only
r ,. Discharges Associated with Construction TPOES Pennit Number: TXR15l_l_l_l_I
• Activity under the TPDES General Permit GIN Number: 1-1-1-1-1-1-1-1
Fee Receipt No.
IMPORTANT:
•Use the attached INSTRUCTIONS when completing this form.
•After completing this form, use the attached CUSTOMER CHECKLIST to make certain all items are complete and accurate.
•Missing, illegible, or inaccurate items may delay final acknowledgment or coverage under the general permit
Application Fee: You must submit the $100 NOI Application Fee to TCEQ under separate cover (see instructions) using the attached Application Fee
submittal form. (DO NOT SEND A COPY OF THE NOi WITH THE APPLICATION FEE SUBMITTAL FORM)
Tell us bow you paid for this fee:
Check/Money Order No.: Name Printed on Check:
.
A. OPERATOR
I. TCEQ Issued Customer Number (CN) (if available):
2. Legal Name (spelled exactly as filed with the Texas Secretary of State, County, or legal document that was used in forming the entity):
E. Hubbard Kennady, Ill, Ltd.
3. Mailing Address: 424 Tarrow Street Suite No./Bldg.No.:
City: College Station State: TX ZIP Code: 77840
4. Phone No.: (979 ) 846-7880 Extension:
5. FAX No. (979) 846-7880 E-mail Address:
6. Type of Operator: Cl Individual Cl Sole Proprietorship-D.B.A. [!]Partnership
Cl Corporation D Federal Government Dstate Government
D County Government CJ City Government CJ other:
7. Independent Operator: l!IYes Cl No (If governmental entity or a subsidiary or part of a larger corporation, check ''NO")
8. Number of Employees: l!.I 0-20; [J2I-100; D 101-250; 0251-500; or D 501 or higher
9. Business Tax and Filing Numbers (not applicable to Individuals, Government, General Partnerships, and Sole Proprietorship-D.B.A):
State Franchise Tax ID Number: Federal Tax ID·
TX SOS Charter (filing) Number: DUNS Number: (If known)
B. Bll.LING ADD~ (1be Operator is responsible for paying the annual fee.)
0 Same As Operator (check if address is the same, then proceed with Section C.)
I. Billing Mailing Address: Suite No./Bldg.No.:
City: State: ZIP Code:
2. Billing Contact (Attn or C/O):
3. Country Mailing Information (if outside USA) Territory: Country Code: Postal Code:
4. Phone No.: ( ) -Extension:
5. FAXNo. E-mail Address:
TCEQ-20022 (07112/2004) Page 1 of3
C. APPLICATION CONTACT (IfTCEQ needs additional information regarding this application, who should be contacted?
I. Name: Rabon Metcalf, P .E. Title: Owner Company: Rabon Metcalf Engineering
2. Phone No.: ( 979 ) 690-0329 Extension:
3. FAX No. (979) 690-0329 E-mail Address: rabon@nnengineer.com
D. REGULA JED ENI1TY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN) (if available):
2. Name of Project or Site: A&M Super Storage, College Station, TX
3. Physical Address of Project or Site: (enter in spaces below)
Street Number: 17309 Street Name: S.H. No. 6 South
City (nearest to the site): ZIP Code (nearest to the site): County (Counties if>l):
College Station 77845 Brazos
4. If no physical address (Street Number & Street Name), provide a written location access description that can be used for locating the site:
(Ex.: 2 miles west from intersection of Hwy 290 & IH35 on Hwy 290 South)
5. Latitude: 30.55958 N Longitude: 96.24791 w
6. Standard Industrial Classification (SIC) code: 1542
7. Describe the activity related to the need for this authorization at this site (do not repeat the SIC and NAJCS code):
Construction of mini-storage and assoicated facilities and improvements.
8. Is the project/site located on Indian Country Lands? Lives l!INo
IfYes, you must obtain authorization through EPA, Region VI.
E. SI'IE MAILING ADD~ (address for receiving mail at the site)
0 Same As Operator (check if address is the same, then proceed with Section F.)
Mailing Address: Suite No./Bldg.No.:
City: State: ZIP Code:
F. GENERAL CBARACTERISIICS
1. Has a Pollution Prevention Plan been prepared as required in the general permit? l!IYes LJNo
If No, coverage may be denied as the PPP is required at the time the NOi is submitted to TCEQ.
2. Provide the estimated area ofland disturbed (to the nearest acre): 3 Acres
3. Provide the name of the receiving water body (local stream, lake, drainage ditch), MS4 Operator (if applicable) and the segment number where storm
water runoff will flow from the construction site.
MS4 Operator: City of College Station Receiving Water Body: Alum Creek Segment: NIA I
TCEQ-20022 (07112/2004) Page2 of3
G. CERTIFICATION
1, E. Hubbard Kennady, Ill
Typed or printed name
Owner
Title (Required)
certify under penalty oflaw that this document and all attachments were prepared under my direction or supervision in accordance with a system designed
to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate,
and complete. I am aware there are significant penalties for submitting fulse information, including the possibility of fine and imprisonment for knowing
violations.
I further certify that I am authorized under 30 Texas Administrative Code §305.44 to sign and submit this document, and can provide documentation
in proof of such authorization upon request.
Date:._~ _ __,_';_PrJ_r/ __ _
TCEQ-20022 (0711212004) PageJ of3