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HomeMy WebLinkAboutNOITHIS FORM REPLACES PREVIOUS FORM 3510-6 (8-98) Form Approved. OMB No. 2040-0188 - See Reverse for Instructions NPDES %, United States Environmental Protection Agency Washington, OC 20460 FORM \� EPA Notice of Intent (NOI) for Storm Water Discharges Associated with CONSTRUCTION ACTIVITY Under a NPDES General Permit Submission of this Notice of Intent constitutes notice that the party identified in Section I of this form intends to be authorized by a NPDES permit issued for storm water discharges associated with construction activity in the State/Indian Country Land identified in Section II of this form. Submission of this Notice of Intent also constitutes notice that the party Identified in Section I of this form meets the eligibility requirements in Part I.B. of the general permit (including those related to protection of endangered species determined through the procedures in Addendum A of the general permit), understands that continued authorization to discharge Is contingent on maintaining pemdt eligibility, and that implementation "a Storm Water Pollution Prevention Plan required under Part IV of the general permit w18 begin at the time the pernittee commences work on the construction project Identified in Secion It below. IN ORDER TO OBTAIN AUTHORIZATION, ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM. 1. Owner/Operator (Applicant) Information {- p 'I p Q L G. Name: LL�1-t ll I ►7 4 Q Wa'tr-I U I I I7� I I I,} 1 I/`1 I I I I I I I I I I Phone: I� 1i 7 �1 � 4 4 6I 613) rm� Of r1m Address: 1� 2i QI Q IW}Q- ad.tJai�ld IPIarlkl IColulrltl 11 1 1 1 1 1 I Owner/OOperetor: City: 1ArJ.17dng UQn I I I I I I I I I I I I I State: I +lx Zip Code: 17 6 Q 131- 1 1 1 11. ProjectiShe Information Is the facility located on Indian Country Lands? {- Project Name: 1Watlel]�WQQd Irk}/�rr onldQm/'A llulm I I I I I I I I I Yes ❑ No [RI Project Address/Location: l renek Map I RdIACentlrlal, Pairfk, LanI AI City: ICQ�.11lege ISltiatlllcm I II , I I I I I State: � Tup Code: J7,814Q-1 I I I Latitude: L� 6 4 J 1 r 16111714151 1 S ra z Q$ 1 Longitude: County 1 1 1 1 1 1 1 1 1 1 1 1 Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes ❑Y No ❑ Optional: Address of location of SWPPP for viewing © Address in Section I above lZAddress in Section 11 above ❑ Other address (If known) below: SWPPP Phone: Address: I I I I 1 I I I I I I I I I I L. I I I I I I I I I I I I I I I I I I I I I I I I I City: 11 I 1 1 I I I I I I I IC I II I I I I I I I State: W Zip Code: I I 11 1 1-1 I I I I cc cQI �ry`I Name of Receiving Water: j�ee lQnee% 11 I}� 1 I I I I I I I I I I 1 1 10131(151a1y1 `�1'JI 10I$1 1 151R 1 "I� Based on instruction provided in Addendum A of the permit, are Month ow %ar Month Day %ar there any listed endangered or threatened species, or designated Estimated Construction Start Date Estimated Completion Data critical habitat in the project area? Estimate of area to be disturbed (to nearest acre): I I 1 1 114I Yes ❑ No Q Estimate of Ukelihood of Discharge (choose only one): I have satisfied permit eligibility with regard to protection of endangered species through the indicated section of Part I3.3.e.(2) 1. ❑ Unlikely 3. © Once perweek 5. ❑ Continual of the permit (check one or more boxes): 2. ❑ Once per month 4. ❑ Once per day (a) Q (b) ❑ (c) ❑ (d) ❑ Ill. Certiticatlon I 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 this system, or those persons directly sible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am at there are significant penalties for submitting false information, Including the possibility of fine and imprisonment for kn violations. Print Name: Date: 1 1 I III i Signature: EPA Form 35 9 laced 351M (8-98) "mauppe s!yl of uu% pala!duwo a4l puss lots GO 'souepuodseum Aue uo Jegwnu Iw1um gy40 e4! epnpul -0960Z '0'0'uol6u!4seM'MN'enua V eluenlAsuued OOZL'AouBov uopelwd p4uewuw!nu3'8TI'(L£LZ) uasv40 uogeuuo;ul ArolelnBea 9ddO 'uoloen0 :o1 uspinq s!yl wnpw Jo meenu! 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OMB No.204MI88 See Reverse for Instructions United States Environmental Protection Agency NPDES Washington, DC 20460 FORM `& EPA Notice o kh of Intent ION)ACTIVITY CONSTRUCTUnder a NPDE3 Gene al permit Submission of this Notice of Intent constitutes notice that the party identified in Section I of this form intends to be authorized by a NPDES permit issued for storm water discharges associated with construction activity in the State/Indian Country Land identified in Section II of this form. Submission of this Notice of Intent also constitutes notice that the party identified in Section I of this form meets the eligibility requirements in Part I.B. of the general permit (including those related to protection of endangered species determined through the procedures in Addendum A of the general permit), understands that continued authorization to discharge is contingent on maintaining permit eligibility, and that implementation of the Storm Water Pollution Prevention Pan required under Part IV of the general permit will begin at the time the permittee commences work on the construction project identified in Secion II below. IN ORDER TO OBTAIN AUTHORIZATION, ALL INFORMATION REQUESTED MUST BE INCLUDED ON THIS FORM. SEE INSTRUCTIONS ON BACK OF FORM. I. Owner/Operator (Applicant) Information {{-- Q '1 p pp GG G IJ41M I�t�IQWa{rlt-1 �17 q1�l 31 Name: �1 I I I 1 11 1 1ryry 1 11 1 I 1 1 1 1 Phone:Status o Address: �20Q Woodland Park Court, I I I I i I I I Owner Operator: 77�� }. r7+y� City: �l?r-I-I it g t,{ Qnl l 1 1 1 1 1 I i I l 1 I Stotts: I LI4 Zip Code: 176 a 14 31- 1 1 1 I II. Project/Site Information Is the facility located on Indian Country Lands? TeT } Project Name: 1WC1t-ITQr1WQQd IQTanidamilniil11AM I I I I I III I Yes NoQ Project Address/Location: lKre[nrr.}}ek{.1Tap RdQQen,tlrall Park ILIaInIel 1It City: I�.IQ��eQe Station Z10lnl I i i StatDe: I J� Zip Code: 177C 410-1 1 3 I$ r1 a 21 Q e 1 1I i i I i Latitude: Longitude: County: Has the Storm Water Pollution Prevention Plan (SWPPP) been prepared? Yes © No Optional: Address of location of SWPPP for viewing Q Address in Section I above Address in Section II above Other address (if known) below: SWPPP Phone: Address 1L I I I I I I I I I I I I I I I I I I I I I I I I City: I I— I I I I I I II I I I I I I I I I I l I State: I Zip Code: I I I I I- I I 11 Name of Receiving Water: F:ii /' r Ie Ii.1k.A I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I Based on instruction provided in Addendum A of the permit, are Month Day Year Month Day Year there any listed endangered or threatened species, or designated Estimated Construction Start Date Estimated Completion Date critical habitat in the project area? Estimate of area to be disturbed (to nearest acre): I I 1 1 114 Yes ❑ No Q Estimate of Likelihood of Discharge (choose only one): I have satisfied permit eligibility with regard to protection of endangered species through the indicated section of Part 1.8.3.e.(2) 1. Q Unlikely 3. Q Once per week 5. 7 Continual of the permit (check one or more boxes): 2. Once per month 4. Q Once per day (a) ❑ (b) (c) ❑ (d) 0 Ill. Certification I 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 this 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 that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. 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A. Cc atrurfilon SRe Operator ®New ©No Change Customer Reference Number. CN Name: Mastertouch Custom Homes Ire, Marling Address: 120D Woodland Park curt _,City:.Arfinaton State: TX,Zip Code: T6013 Country Mailing Iniortnation (rfoutsida USA) Territory:^. __Country Cotic: Postal Code; Phone Number._ 817-99416 3 _Fax Number._ 817.422-8664 .� Extension: E-main Address:.jpstevrart®attbLcom - TypeofOperator. ©IndividuN ©Sole Propdeicrship-D.B.A. ©Pannersh)p ®Corporation ©Federal Govemment © State Government ©County Government ©City Government ®Other. Independent Operator? Yes ©140 Number of Employees: -20 © 21-100 [3101-250 © 251-500 171501 orhigher madame! Tax 0: T•$" i0r0347 Salta Franchise Tax ID Number. GUNS Number. B- Billing Address — Name:_Mastanouch Custom Humes. Inc Mailing Address: 4200 Woodland Park Cou City: Arlington !,Stale: TX Zrp Code; 7601s _ Country Mailing Information (rYoutside USA) 7emtory:_, _Country Coda: _Postal Code: C. P"Ject7 Site Information ®New il]No Change Regulated Enlay Reference Number. RN Name: Waterwood Townhomes Maring Address PTO, Box 10028 City; C. oiled! Station State: TX Zip Code: 77842-9901 Physical Address:208 southwest Perllwav Clty:Colleoe Stadon_,County sRUxts Zip Code: 77340 Location Access Description: Krarrek lip Road ® Central Park Lane Latitude: _19_• 36 , 47 " N Longitude: 96 ° 17 ' 45 " W T Degrees (•), Minutes (7, and Seconds C) Lathude:_ Longitude: -- Decimal Form Slendard 1ndush"" Classlitca0on (SIC) code: 1521 Also, describe the construction activity at this site (do not repeat the SIC 00461: ConstmoillonofTownhomes _ Has a storm water poluton prevention plan been prepared as specified in the general permit (TXR150000)? ® Yes [3 No Estimated area offend disturbed (to the nearest acre): 14 _ Is the project / site located on Indian Country Lands? ® Yes ® No Does this project I site discharge storm water into a municipal separate storm sewer system (MS4)? ® Yes ® No If yes, provide the name of the MS4 operalor C,�it r of C�n Provide the name or segment number of the water body that receives storm water from this pmjecl t site; Bea Creek D. Contact - If the TCEQ needs additional information regarding this applkal on who slroggid be contacted? Name: Jim Stewart Tllie:_ �tc1�t4r1} Phone Number. SIT994.4663 Extension;_ —Fax Number: 817429-3664 E-maii Address: lbstewart0aftbi.com E. Payment lnforinatton- Check/Money Order Number. Qf•/ Nameon Check/MonevOA e4 L L .�riL►1/� F. Certification I ooruty underpswity of law that this ommem"s prepared under my direction orsupewis)oa in accordance with a system designed to assure thatqua)med Personral wopertygalherandevalate the Information submitted. Bandon myinquiry of the personor personswhomanage fie system, or thosepersons dttediy responsible forgathering the Information. the information submitted 4 to the best of my knowledge and belief. We, aoourate, and compote. tam aware !hare are sfgnlDranl penalties for submitting false Information. incWoing the Possibtity or fine and Impdsomnent forknowirg violations. C/nstmctlon Site Operator Representarme: Prefix: First:. c/ /J .6�5 Middle:-_� Last• S T6'W /}.P T _Suffer Title:_�fa?6Y /D6 �/� Signature: Dale: +-/% 03 if you ha ns o taf to fit 0m this foml or about 16 storm water program, please Contact us at (512) 239-4971. Indlvitlua enuaed to request and revfew1heirpersanal information that the agencygatherson Its forms. They may eiso have arryermrs intheirrnformaton co ed. To reviamv such informauur contact us at (512) 239-3282. The completed N01 must be malted to the following address. Use the attached document to submit the $100 application fee. Please note that the N01 and apPl)Callon fee are submitted separately to dlBerent addresses. Texas Commission on Environmental Quality Storm Water & General Permits Team; MC -228 P.O. Box 13087 Austin, Texas 78711-3087 TCE0,20022 (02/03) Page 1 of 2