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-W Notice 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: •_•� •� •� •_•_•� ••
help completing this application, read the TXR150000 NOI Instructions
TCEO For
(TCEQ-20022-Instructions).
A.
Construction Site Operator []New r1No Change Customer Reference Number: CN
Name:
Mailing Address: City: State: Zip Code:
Country Mailing Information (if outside USA) Territory: Country Code: Postal Code:
Phone Number: Extension: Fax Number:
E -mail Address:
Type of Operator: D Individual [I Sole Proprietorship - D.B.A. El Partnership r] Corporation D Federal Government
n State Government 171 County Government [] City Government Other:
Independent Operator? 171 Yes No Number of Employees: 0 -20 21 -100 [1101-250 171251-500 171501 or higher
Federal Tax ID: State Franchise Tax ID Number: DUNS Number:
B.
Billing Address
Name:
Mailing Address: City: State: Zip Code:
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:
Mailing Address: City: State:_ Zip Code:
Physical Address: City: County: - Zip Code:
Location Access Description: l� ° F u i y %` '� -Jt i � ' .psi • 'w -A k, ,,
Latitude:_' 2 " N Longitude: ° " ' -1 W IJ; ' T Degrees ( °), Minutes k'), and Seconds ( ")
Latitude: Longitude: - Decimal Form
Standard Industdal Classification (SIC) code: Also, describe the construction activity at this site (do not repeat the SIC code):
Has a storm water pollution prevention plan been prepared as specified in the general permit (TXR150000)? 171 Yes No
Estimated area of land disturbed (to the nearest acre): Is the project / site located on Indian Country Lands? l] Yes No
Does this project / site discharge storm water into a municipal separate storm sewer system (MS4)? []Yes No
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:
D.
Contact - If the TCEQ needs additional information regarding this application, who should be contacted?
Name: Title:
Phone Number: Extension: Fax Number:
E -mail Address:
E.
Payment Information - Check / Money Order Number: Name on Check / Money Order:
F.
Certification
I certify under penalty of lawthat this documentwas 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:
Prefix: First: Middle:
Last: Suffix: Title:
Signature: Date:
If you have questions on how to fill out this form or about the storm water program, please contact us at (512) 239 -4671.
Individuals are entitled to request and reviewtheir 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 8, General Permits Team; MC - 228
P.O. Box 13087
Austin, Texas 78711 -3087
TCEQ -20022 (05/03) Page 1 of 2
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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
BY OVERNIGHT /EXPRESS MAIL
Texas Commission on Environmental Quality
Financial Administration Division
Cashier's Office, MC -214
12100 Park 35 Circle
Austin, TX 78753
Fee Code: GPA
Check / Money Order No:
Date of Check or Money Order:
Name on Check or Money Order:
Facility / Site Name:
Facility / Site Physical Address:
City:
Storm Water General Permit: TXR150000
Amount of Check/Money Order:
Zip Code:
Staple Check In This Space
TCEQ -20022 (05/03) Page 2 of 2