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Home My WebLink AboutNOINotice of Intent (NOI) for Storm Water Discharges TCEQ Office Use Only Associated with Construction Activity under the TPDES Permit Number: TXR15•_•_ _ _-•- NO TPDES Construction General Permit(TXR150000) GIN Number: •• •• •• •• •• •• •• TCEOFor help completing this application, read the TXR150000 NOI Instructions (TCEQ-20022-instructions). A. Construction Site Operator New []No Change Customer Reference Number. CN Name: l�IA2K IL50,'JgA,J Mailing Address: 706 &I, SLMS 5 City: tit State:�Zip Code:- -:13 Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: Phone Number: T�n�t ,F5Z2 37G"7 /l Extension: Fax Number: C%7c/ L?ZZ 7G04 E-mail Address: /'/.d��t�BJ �r-/A/JAhI 0 ADL- . CG,M Type of Operator:-olndividual Q Sole Proprietorship - D.B.A. Q Partnership E] Corporation Q Federal Government F7 State Government ® County Government 0 City Government n Other: Independent Operators Il Yes [I No Number of Employees: [10-20 El 21-100 ® 101-250 [1251-500 0 501 or higher Federal Tax ID: State Franchise Tax ID Number. DUNS Number: B. Billing Address Name: Afue.. Bo'CNq nt/JAl Mailing Address: Z06 tA- SfM$ 57YL£AT' City: &YAM State:T,- Zip Code: %73b3 Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: C. Project / Site Information ONew E]No Change Regulated Entity Reference Number. RN Name: (fUZFiQNAtiI 17E3fVCNGE Mailing Address: Z-rG 1`450S S City: B,�YAAt State:Z Zip Code: 77��3 Physical Address: ezaiozdt,D PA,Z1.u,'w City:6tzaE 5i w7cU County: - &J2-05 Zip Code: 77651 Location Access Description: 6DAAJ9X �'F ENI0z44,5 F'42Xw41 S �t'W t'Av- 4--mix Latitude:--3&'41 " N Longitude:°I ko' .�& W Degrees I'), Minutes ('), and Seconds (") Latitude: - Longitude:- Decimal Form Standard Industrial Classification (SIC) code: 15Z ( Also, describe the construction activity at this site (do not repeat the SIC code): 5IA14LC FAAt fLY 2t�;sIDaP4n,0- eoALyi7wcncw Has a storm water pollution prevention plan been prepared as specified in the general permit (TXR150000)? MYes n No Estimated area of land disturbed (to the nearest acre): At— Is the project / site located on Indian Country Lands? E] Yes)3JNo Does this project / site discharge storm water into a municipal separate storm sewer system (MS4)? )]Yes MNo If yes, provide the name of the MS4 operator: Provide the name or segment number of the water body that receives storm water from this project / site: 36r Cam. D. Contact - Ifr the TCEQ needs additional information regarding this application, who should be contacted? Name: NAP,,- 51ZgAiJAAt Title: A-99470Z- Phone Number: T79 122- 3767 Extension: Fax Number: 772 S7ZZ 760 4- E-mail Address: tJA9LG1J 5U&gAAb4Af E. Payment Information - Check / Money Order Number: Name on Check / Money Order: F. Certification I certify under penalty of law that this document was 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. Construction, Site Operator Representative: Prefix: MP First: 1(44ak- Middle: k4462V—Dw Last:_ fit,-A.1/"A'i Suffix: 01'6224TDt Signature: - Date: 3 AP/L (03 If you have questi s on h to f ut thi rm or about the storm water program, please contact us at (512) 239-4671. Individuals are entit a eview their personal information that the agency gathers on its forms. They may also have any errors in their information corrected. To review such information, contact us at (512) 239-3282. The completed NOI must be mailed to the following address. Use the attached document to submit the $100 application fee. Please note that the NOI and application fee are submitted separately to different addresses. Texas Commission on Environmental Quality Storm Water & General Permits Team; MC - 228 P.O. Box 13087 Austin, Texas 78711-3087 TCEQ-20022 (02/03) Page 1 of 2 Texas Commission on Environmental Quality Payment Submittal Form The storm water application fee shall be sent under separate cover to the Texas Commission on Environmental Quality. This form must be used to submit your Storm Water Application Fee. Please complete the following information, staple your check in the space provided at the bottom of this document, and mail it to: BY REGULAR U.S. MAIL Texas Commission on Environmental Quality Financial Administration Division Cashier's Office, MC-214 P.O. Box 13088 Austin, TX 78711-3088 Fee Code: GPA BY OVERNIGHT/EXPRESS MAIL Texas Commission on Environmental Quality Financial Administration Division Cashier's Office, MC-214 12100 Park 35 Circle Austin, TX 78753 Storm Water General Permit: TXR150000 Check / Money Order No: to /cc225- Amount of Check/Money Order: 0)00. Date of Check or Money Order: Ze Afe- t03 Name on Check or Money�Le Order: /. a FJcd� . aa,"(%n/ Facility / Site Name: BUG/ ,",61 / /24E5 /1)E7466 Facility / Site Physical Address: 6--N wV ,q 1 42KL y S 66�AiT 64K %u u6 City: ��Z-� � :/Td07704 Zip Code: 7[J�S MARK W. BUCHANAN BONNIE S. BUCHANAN BUSINESS ACCOUNT 2401 E. BRIARGATE BRYAN, TX 77802 88-230/1131 700749517 DATE 2- Al�zDG 1015 PAY TO THE ORDER O/ n•wW!•y�7�.iLI/$ 19 FTitBT NATIONAL 8T BANH Aga e«e MEM0401 uxwez TX!L/5D", 1:1131023031: 10151I'700?i gSI?Ila DOLLARS u Prestige Plus TCEO-20022 (02/03) Page 2 of 2