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Home My WebLink AboutNOI. t'\ To' Notice of Intent (NOi) for Storm Water Discharges Associated with Construction Activity under TPDES General Permit (TXR150000) RN: CN: Ref No: Sign up now for ePermits NOi at www6.tceg.state.tx.us/steers Get Instant Permit Coverage and only pay a $225 application fee . If filing a paper NOi you can pay the application fee on line? Go to www.tceg.state.tx.us/epav Select Fee Type: GENERAL PERMIT CONSTRUCTION STORM WATER DISCHARGE NOI APPLICATION If submitting a paper NOI, coverage under the genera~ pennit starts seven (7) days after the date postmarked for delivery to TCE . Renewal of General Permit Is this NOI to renew an ACTIVE permit? 0Yes -What is your permit number? Permit No. TXRlS _______ _ ~o - a permit number will be issued. Application Fee if mailing a paper NOi: You must pay the $325 Application Fee to TCEQ for the application to be considered complete. Payment and NOI must be mailed to separate addresses. See instructions for correct mailing addresses. Provide your payment information below, for us to verify payment of the application fee: Check/Money Order No.: Company Name on checking account: WAL j E. R p Voucher No.: Is the Payment Voucher copy attached? DYes ooRE 1. If the applicant is currently a customer with TCEQ, what is the Customer Number ( CN) issued to this entity? CN (Search Central Regish·y) 2. What is the Legal Name of the entity (applicant) applying for this permit? LD\..LC:Gt S\,b..\\ON MAR'i..E.\P\.Ac..EJ L .?. (The legal name must be spelled exactly as filed with the Texas Secretary of State, County, or in the legal document f orming the entity.) 3. What is the name and title of the person signing the application? (The person must be an official meeting signatory requirements in TAC 305.43(a).) Name: Job Title: '\)RE.S \ t)E >J'\ 4. What is the Operator's (applicant) mailing address as recognized by the US Postal Service? (verify at USPS.com) City: H 0 \):S\ 0 lJ State: tE. ~A. S ZIP Code: ':J ~ 02. T Country Mailing Infonnation (if outside USA). A Country Code: Postal Code: 5. Phone No.: (":f \3) b2.'3-O\~% 6. Fax No.: ('::1\'~) 6'20-Ql"=lcg 7. Indicate the type of Customer: D Individual D Corporation D State Government Dother Government TCEQ-20022 (03/05/2008) Extension: N/A E-mail Address: And We\ oe~ Oso!e Proprietorship-D.B.A. 0Federal Government [}'.::ounty Government Oother (describe): 1:!1Zimited Partnership 0General Partnership Deity Government Page 1 ·. , 8. Independent Operator: 5i:]fYes [J)No (If governmental entity, subsidiary, or part of a larger corporation, check ''No".) 9. Number of Employees: [if0-20; 021-100; 0101-250; 0251-500; or 0501 or higher 1 O. Customer Business Tax and Filing Numbers (This item is not applicable to Individuals, Government, GP or Sole Proprietor.) REQUIRED for Corporations and Limited Partnerships (Verify the entity's status and filing no. with TX SOS at 512/463-5555) State Franchise Tax ID Number: '320354 25S03 I Federal Tax ID: 20-302 \ 232. TX SOS Charter (filing) Number: ~ 00 14044 I DUNS Nijl]lber (if known): N/A. -~.)IP;!~#,_, --· · ... ~. :·_ · -· , . .,.,","'"o .,,. «' ·. """ · .-:~-r-'• ;._', -·.-. ·. --: · .-· ·-:., .. -·, ' .,-~r '" -•I· --' c •t"·A -1 If TCEQ needs additional information regarding this application, who should be contacted? 2. Phone No.: ('=\ \"~ ) b30-l 33~ Extension: )J/A 1. TCEQ Issued RE Reference Number (RN): RN (Search Central Ree:istrv) 2. Name of Project or Site (the name as known by the community where this facility/project is located): \o\/JER Po \t.l\ (example: phase and name of subdivision or name of project that's unique to the site) 3. Does the site have a physical address? If Yes, complete GM for a physical address. If No, complete s\tfilfMm for site location information. Enter the physical address for the site. (verify it with USPS.com or other delivery source) Street Number: Street Name: City: Zll' Code: Enter the site location information. If no physical address (Street Number & Street Name), provide a written location access description to the site: (Ex.: phase 1 of Woodland subdivision located 2 miles west from intersection of Hwy 290 & IH35 accessible on Hwy 290 South) WE~\ \l'l"tER~e<:..'T\ON Cf ~)\A\E. \-\\r( ' :TA""\C:. \-\ '( 40 City where the site is located or nearest city to site: ZIP Code where site is located: 5. Latitude: Longitude: 't<e,ZE><o 0 W 6. What is the primary business. of this entity? In your own words, briefly describe the primary business of the Regulated Entity: (Do not repeat the SIC andNAlCS code) RE.TA\ L \:)E.'l~LOf'ME.NT 7. What is the mailing address for the regulated entity? Is the RE mailing address the same as the Operator? es, address is the same as Operator No, provide the address Street Number: Street Name: 0Yes -If Yes, do not submit this NOL Contact EPA, Region VI If the site is on Indian coun lands, ou must obtain authorization throu EPA, Re 'on VI. 2. What is the Standard Industrial Classification (SIC) code (see instructions for common codes): • (Search Osha.gov) Primary: \ 54 2. Secondary: } f, 23 TCEQ-20022 (03/05/2008) Page2 3( a) What is the total number of acres disturbed? 3(b) Is the project site part of a larger common plan of development or sale? Yes If Yes, the total number of acres disturbed can be Jess than 5 acres. If No, the total number of acres disturbed must be 5 or more. If the total numper of acres disturbed is less than 5 then the project site does not qualify for coverage through this Notice oflntent. Coverage will be denied. See the requirements in the eneral ermit for small construction sites 4( a) What is the name of the water body( s) to receive the storm water runoff or potential runoff from the site? Sf>R l ~G C~EC.¥-. 4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventUally reach? \2 09 4( c) Are any of the surface water bodies receiving discharges from the construction site on the latest EPA-approved CW A 303( d) list of impaired waters? ~es 0No If Yes, rovide the name of the im aired water bod 4(d) Is the discharge into an MS4? 0Yes IfYes, what is the name of the MS4 Operator? _________________________ _ Note: The general permit requires you to send a copy of the NOI to the MS4 Operator. 4( e) Is the discharge or potential discharge within the Recharge Zone, Contributing Zone, or Contributing Zone within the Transition Zone of the Edwards Aquifer? 0Yes ~o If the answer is Yes, please note that a copy of the agency approved Plan required by the Edwards Aquifer Rule (30 TAC Chapter 213) must be included or referenced in the Storm Water Pollution Prevention Plan. Check "Yes" to the certifications below. Failure to certify to all items will result in denial. I certify that I have obtained a copy and understand the terms and conditions of the general permit CTXRl 50000). I certify that the full legal name of the entity (Operator) applying for this permit has been provided and is legally authorized to do business in Texas. Yes I understand that a Notice of Termination (NOT) must be submitted when this authorization is no longer needed. Yes I certify that a storm water pollution prevention plan has been developed and will be implemented prior to construction, and that is compliant with any applicable local sediment a.'1d erosion control pla..'1s, as re uired in the eneral ermit TXR150000. I, _.,.A ..... N..,D'<'......_W........,_E;;,,m\N._.. £.;iiiiiiiliR.__ ___ _ Typed or printed name (Required & must be legible) Title (Required & legible) certify under penalty of law 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 false information, including the possibility of fine and imprisonment for knowing violations. I further certify that I am authorized under 30 Texas Administrative Cocle §305.44 to sign and submit this document, and can provide documentation in Date:.---l--'-'l{(u=----1-(o_"f __ Page 3 ·, . . Did you complete everything? Use this checklist to be sure! Are you ready to mail your form to TCEQ? Go to the General Information Section of the Instructions for mailing addresses. ·Customer GP Notice of Intent Checklist TXR150000 .f This checklist is for use by the operator to ensure a complete application. Missing information may result in denial of coverage under the rmit. See NOI Process descri tion in the Instructions Application Fee of $325.00 was mailed se aratel to TCE 's Cashiers's Office se arate from the NOI or the EPA Y a ment voucher is attached. OPERATOR INFORMATION -Confirm each item is complete: .f ustomer Number (CN) issued by TCEQ Central Registry Legal Name as filed to do business in Texas (Call TX SOS 512/463-5555) Name and Title of person signing the application. This person must meet signatory requirements in 30 TAC Section 305.43 Operator Mailing Address is complete & verifiable with USPS. www.usps.com Pl!_one Numbers/E-mail Address Type of Operator (Entity Type) Independent Operator umber of Employees For Co orations or Limited Partnershi s -Tax ID and SOS Filin REGULAT:Ji;D ENTITY (RE) INFORMATION ON PROJECT OR SITE -Confirm each item is complete: .f Regulated Entity Reference Number (RN) (if site is already regulated by TCEQ) Site/Project Name/Regulated Entity Site/Project (RE) Physical Address Please do not use a rural route or post office box for a site location Or if no physical address, the location information that includes description, zip code and city is listed. titude and Longitude TCEQ USGS Topographic Map Viewer or TmaServer-USA Business description Site Mailin Address checked same as o erator or com lete & verifiable with USPS. www.us s.com GENERAL CHARACTERISTICS -Confinn each item is complete: .f dian Country Lands -the facility is not on Indian Country Lands Standard Industrial Classification (SIC) code www.osha.gov/oshstats/sicser.html 11.cres Disturbed is provided and qualifies for coverage through a NOI. ommon plan of development or for sale? ischarge Information: eceiving water body segment number(s) is REQUIRED water body on the latest EPA-Approved Clean Water Act 303(d) list of impaired waters S4 Operator Edwards A uifer Rule CERTIFICATION Certification statements have been checked indicating "Yes" Signature meets 30 Texas Administrative Code CfAC) §305.44 and is original and has been provided for the Operator. TCEQ-20022 Checklist (03/05/2008) Page 1