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r ill Notice of Intent (NOI) for Storm Water Permit No.: TXR15
Discharges Associated with Construction RN:
IDIOM
Activity under TPDES General Permit CN:
TCEC) (TXR150000) Ref No:
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.o:°•. If filing a paper NOI you can pay the
NOI at www6.tceq.state.tx.us /steers
and only pay a $225 application fee.
application fee on line? Go to https : / /www6.tceq.state.tx.us /epay/
IMPORTANT:
•Use the INSTRUCTIONS to fill out each question in this form.
•Use the attached CUSTOMER CHECKLIST to make certain all you filled out all required information.
•Incomplete applications WILL delay approval or result in automatic Denial.
Renewal of General Permit
Is this NOI to renew an ACTIVE permit?
Yes - What is your permit number? Permit No. TXR15
No - a permit number will be issued.
/2.</
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:
Mailed:
Check /loney Order No.:
Company Name on checking account:
EPAY:
Voucher No.:
Is the Payment Voucher copy attached? Yes
A. OPERATOR (applicant)
1. If the applicant is currently a customer with TCEQ, what is the Customer Number (CN) issued to this entity?
CN (Search Central Registry)
2. What is the Legal Name of the entity (applicant) applying for this permit?
,. . .0/CJ —Z —Z i 1 74 4 4 )',2,7'. /. 2 /
(The legal name must be spelled exactly as filed with the Texas Secretary of State, County, or in the legal doormen: forming the entity.)
3. What is the name and title of the person signing the application? �� e' f � ro Q / ��
(The person must be an official meeting signatory requirements in TAC 305.43(a).) "- /
Name: 7
Job Title:
4. What is the Operator's (applicant) mailing address as recognized
by the US Postal Service? (verify at USPS.com)
Address: /9'2 ,ih.oh � Suite NoJBldg. No./Mail Code:
City: �� l/e y? .Sf- ,'ti State: 7-�f` ZIP Code: ��J�
7
Country MailifInformation (if outside USA). Country Code: Postal Code:
5. Phone No.: (977) `33 9 7
Extension:
6. Fax No.: ( )
E -mail Address:
7. Indicate the type of Customer:
❑
DOther
ndividual ❑Sole Proprietorship- D.B.A. ❑Limited Partnership
C orporation ❑Federal Government ❑General Partnership
State Government ❑County Government ❑City Government
Government ❑ Other (describe):
TCEQ -20022 (03/05/2008)
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8. Independent Operator: Yes ■ No (If governmental entity, subsidiary, or part of a larger corporation, check "No ".)
9. Number of Employees: • 0-20; 100; • 101 -250; • 251 -500; or • 501 or higher
10. 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 A
State Franchise Tax ID Number:
Federal Tax ID: y4 )' 2 2
TX SOS Charter (filing) Number:
DUNS Number (if known): .�� /f��1�1
B. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1 . Name: Q > /r�
�l+ led W
Title: /
� P��' �f u� � 17-77 � �. p� �
C o m A y: , z �� .„ /�
.� i
4,,,,,
2. Phone No.: ( 997) 2 2 O _ y/ 94
Exte ion:
3. Fax No.:
E -mail Address: a nu'� 6 r - ' X.f ,.-/,- - - - a,v,
C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN): RN
(Search Central Registry)
2. Name of Project or Site (the name as known by the community where this facility /project is located):
,D- ,.8r9 4 -' 17 71'C''7', �," -/ G /o. / I f
(example: phase and name of subdivision or name of project that's unique to the site)
3. Does the site have a physical address? ��ff
If Yes, complete Section :A for a physical address. i f a2 1: 'Re/
If No, complete Section B for site location information.
Beetles A. Enter the address for the site (verify it with USPS.com or other delivery source)
physical
Street Number:/4j77 t.,.,,. ,Q,,,
Street Name:
.A
City: /:!,// C f fy �. l., N
ZIP Code: �j?�S
Bettie* .B Enter the sitelocation 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)
City where the site is located or nearest city to site:
ZIP Code where site is located:
4. Identify the county where the site is located: L5 Ul /9 2 4._.<.
5. Latitude: �� e ,32 / y , 'i
Longitude: 9/ ° ,j n
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 and NAICS code)
7. What is the mailing address for the regulated entity? fc�/_o " > 1
Is the RE mailing address the same as the Operator? C]Yes, address is the same as Operator
MI No, provide the address
Street Number: /9,,, 2 , /ce
Street Name:
City:
r�j��f � Ski f�� � �
State: 7—X
ZIP Code: 2�� s
D. GENERAL CHARACTERISTICS
1. Is the site located on Indian Country Lands? / No • Yes — If Yes, do not submit this NOI. Contact EPA, Region VI
If the site is on Indian country lands, you must obtain authorization through EPA, Region VI.
2. What is the Standard Industrial Classification (SIC) code (see instructions for common codes): (Search Osha.eov
Primary: 13 7-7/ Secondary:
TCEQ -20022 (03/05/2008)
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