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HomeMy WebLinkAboutNOITCEQ Office Use Only Notice of Intent (NOI) for Storm Water Permit No.: TM Discharges Associated with Construction RN: Activity under TPDES General Permit CN: TCEQ (TXR150000) Ref No: Sign up now for ePernuls NOI at tyww6.tcea .staIeJx.ns /steers Get Instant Permit Coverage and only pay a 5225 application fee. e If filing a paper NOI you can pay the application fee on Tiny Go to www.tceu.state.U.usleosv Select Fee Type: GENERAL PERMIT CONSTRUCTION STORM WATER DISCHARGE NOI APPLICATION If submitting a paper NOI, coverage under the general permitsuats seven (T) days after the date postmarked for delivery to TCEQ. 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? QYes - What is your permit number? Permit No. TXR15 E ]No - a permit number will be issue[. Application Fee if mailing a paper NOI: You must pay the S325 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/Money Order No.: Company Name on checking account LJ EPAY: Voucher No.: Is the Payment Voucher copy attached? ❑ Yea A. OPERATOR (applicant) 1. If the applicant is currently a customer with TCEQ, what is the Customer Number (CN) issued to this entity? CN 601162985 (Search Cen ra 1 i 2. What is the Legal Name of the entity (applicant) applying for this permit? Chick- fil -A, Inc. (The legal name mun htcpelledexattly at fled with the recta Secretary of State. County, or in the legal document forming the endry.) 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: Matthew B. Stellmaker I Job Title: Development Manager 4. What is the Operator's (applicant) mailing address as recognized by the US Postal Service? (verify at USPS.comt Address: 5200 Buffington Road Suite No./Bldg. No.Abil Code: city :AUanta I Stau`GA ZIP Coda 30349 -2998 Country Mailing Information (if outside USA). Country Code: Postal Code: 5. Phone No.: (404 ) 765 -8028 extension: 6. Fax No.: ( 404 ) 664 -8550 E -mail Address: 7. Indicate the type of Customer: Individual ©Sole Proprietorship- D.B.A. ❑Limited Partnership Corporation OFederal Government (]General Partnership ©State Government EDCounty Government IICit Government ©Other Government Other (describe): TCEQ -20022 (03/05/2008) Page 1 8. Independent Operator. I,+�Yes ❑No (If governmental entity, subsidiary, or pan of a larger corporation, cheek "No ".) 9. Number of Employees: ❑0 -20; pzl -too; [3101 -250; C3251-500; or p501 orhigher 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 ( v erity the entity's status and filing no. with TX SOS at 512/463 -5555 State Franchise Tax ID Number: Pederal Tax ID: 58- 0941582 TX SOS Charter (filing) Numbs. DUNS Number (if known): B. APPLICATION CONTACT If TCEQ needs additional information regarding this application, who should be contacted? 1. Name: Natalie Knowles 1 tl Design and Construction Company: Chick -fll-A, Inc. 2. Phone No.: ( 404 ) 765 -8028 ErhtersO ": 3. Fast No.: 404 685 - 8550 E-mail Address: natalie.knowles@chick-fil-a.com C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE 1. TCEQ Issued RE Reference Number (RN): RN (Search Central Reaistrvl 2. Name of Project or Site (the name as known by the community where this facility /project is located): Chick -fil -A - College Station (Spring Creek Commons), TX #2822 (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 Seefimi for a physical address. If No, complete Seelu.P, B for site location information. Section A Enter the physical address for the site. (verify it with US S.com or other delivery source) Street Number. Street Name: City: ZIP Code: Sell ABi 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) North Quadrant of State Hwy 6 South and William D. Filch Pkwy City where the site is located or neareat city to site: College Station ZIP Code where site is located: 77845 4. Identify the county where the site is located: Brazos 5. Latitude: 30 33 40 i Longitude: -96 15 32 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 NAILS code) New Commercial Construction - construct Chick -fil -A restaurant and parking lot 7. What is the mailing address for the regulated entity? Is the RE mailing address the same as the Operato(1 L!JYes, address is the same as Operator No, provide the addres s Street Number: Street Name: City: state: ZIP Code: D. GENERAL CHARACTERISTICS 1. Is the site located on Indian Cou 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 ch ha,flo y > Primary: 1542 Secondary: TCEQ -20022 (03/052005) Page 2 3(a) What is the total number of acres disturbed? 2 3(b) Is the project site part of a larger common plan of development or sale? ElYes O NO If Yes, the total number of acres disturbed can be less than 5 acres. If No, the total number of acres disturbed must be 5 or more. If the total number of acres disturbed is less than 5 then the project site does not qualify for coverage through this Notice of Intent Coverage will be denied. See the requirements in the eneral vermit for small construction sites. 4. Dfa4barge Inffirmation (all htfornint(on MOST be provided bt'ilfe permit will be denied) 4(a) What is the name of the water body(s) to receive the storm water runoff or potential runoff from the site? Unnamed tributary to Spring Creek to unnamed tributary to Peach Creek to Navasota River 4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventually reach? 1209 4(c) Are any of the surface water bodies receiving discharges from the construction site on the latest EPA - approved CWA 303(d) list of impaired waters? ® Yes ED No If Yes provide the name of the impaired water bod s . 4(d) Is the discharge into an MS4? QYes ©No If Yea, what is the name of the MS4 OperattiO of College Station Note: The general permit requires you to send a copy of the Not 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? [__1 Yes El No 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. E. CERTIFICATION Check "Yes" to the certifications below. Failure to certify to all items will result in denial. © Yes I certify that I have obtained a copy and understand the terms and conditions of the fteneral permit (TXR 150000) [✓ Yes 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 Q Yes I certify that a storm water pollution prevention plan has been developed and implemented prior to construction, and that is compliant with any applicable local sediment and erosion control plans and prepared and implemented asrequiredintheit eralpennitTXR150000. Operator Certification: Matthew B. Stellmaker Development Manager Typed or printed name (Required& muar ge Tide (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 orpersum who manage the system, or those persons directly responsible for gathering the information, the infomution submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for subrititting false information, including the possibility of One and imprisonment for knowing violations. 1 farther certify that I am authorized wider 30'rexas Adminixtrative Code 6305.44 to sign and submit this document, and can provide documentation in proof of such authorization upon request. Signature Date: salA ink r(:EQ -20022 (03105/2008) Page 3