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HomeMy WebLinkAboutTECQ PERMIT - D-P- _ may✓ tr 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: •• •• •• •• •• .• .• •• TcEQ For help completing this application, read the TXR150000 NOI Instructions (TCEQ 20022 Instructions). A. Construction Site Operator New ®No Change Customer Reference Number: CN Name: Brazos Valley Services Mailing Address: P. 0. Box 985 City: Bryan State: TX Zip Code: 778069 Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: Phone Number: 979- 255 -3977 Extension: Fax Number: 936- 399 -7012 E -mail Address: emop d txcyber.com Type of Operator: 0 Individual ® Sole Proprietorship - D.B.A. 0 Partnership ® Corporation 0 Federal Government © State Government 0 County Government 0 City Government ® Other: Independent Operator? ® Yes 0 No Number of Employees: © 0 -20 ® 21 -100 0 101 -250 0 251 -500 Federal Tax ID: 742978052 State Franchise Tax ID Number: 501 or higher DUNS Number: B. Billing Address Name: Brazos Valley Services Mailing Address: P. 0. Box 985 City: Bryan State: TX Zip Code: 77806 Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: C. Project / Site Information New ®No Change Regulated Entity Reference Number: RN Name: Edward Froehling - Shenadoah Subdivision Mailing Address: P. 0. Box 985 City: Bryan State: TX Zip C ode: 77806 Physical Address: No Address City: College Station County: -- Y ) 'Zpde:77845 Location Access Description: Alexanderia & Southern Plantation Streets, College Station, TX 77845 PilA3 0. Q 1 Latitude: 30 ° 34 ' 9 " N Longitude: " ' ° 6 16 28 W e Degrees ( Minutes ('), and Seconds ( ") Latitude: Longitude: Decimal Form Standard Industrial Classification (SIC) code: 1 CP t 1 Also, 40300e 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)? an Yes 0 No Estimated area of land disturbed Ito the nearest acre): 50 Is the project / site located on Indian Country Lands? 0 Yes OM No Does this project / site discharge storm water into a municipal separate storm sewer system (MS4)? 0 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: Tributary C of Spring Creek 0. Contact - If the TCEQ needs additional information regarding this application, who should be contacted? Name: Ricky Palasota Title: Owner, Brazos Valley Services Phone Number: 979 - 255 -3977 Extension: n/a Fax Number: 936- 399 -7012 E -mail Address: emop@txcyber.com E. Payment Information - Check / Money Order Number: 7358 Name on Check / Money Order: Brazos Valley Services 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: Prefix: Mr. , First: Ric ; Middle: J. Last: Palasota AN 1 IMI Suffix: n f Title: Owner, Brazos Valley Servi es Signature: L , ,��` - _ - i �- Date: 2 3 o If you have questions on ho to ti out this form or about the storm water program, please contact us at (512) 239 671. Individuals are entitled to request and review 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 (05/03) 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 BY OVERNIGHT /EXPRESS MAIL Texas Commission on Environmental Quality Texas Commission on Environmental Quality Financial Administration Division Financial Administration Division Cashier's Office, MC -214 Cashier's Office, MC -214 P.O. Box 13088 12100 Park 35 Circle Austin, TX 78711 -3088 Austin, TX 78753 Fee Code: GPA Storm Water General Permit: TXR150000 Check / Money Order No: 7358 Amount of Check/Money Order: 100. UD Date of Check or Money Order: to ' l $ °3 Name on Check or Money Order: Brazos Valley Services Facility / Site Name: Edward Froehling • Shenadoah Subdivision Facility / Site Physical Address: No Address City: College Station Zip Code: 77845 Acct #: 7358 BRAZOS VALLEY SERVICES 979 - 255.3977 979- 229 -8450 PLANTERS AND MERCHANTS STATE BANK P.O. BOX 985 88- 381 -1119 BRYAN, TEXAS 77805 DATE AMOUNT Jun 18, 2003 * * * * * * * * * * * * *• *.$100 DAY One Hundred and 00 /100 Dollars rO THE JRDER DF Texas Commission on Environmental Quali P.O. Box 13088 Cashier's Office, MC -214 Austin, TX 7871 1 -3088 ,,...._ --- ' hr 000 7 3 58P 1: 1 L 190 38 181: ii•g0 9 7 3 5 9u -_- _-- - - - - -- TCEQ -20022 (05/03) Page 2 of 2 Invoice # Description Invoice Date Invoice Amount Discount Amount Paid Enrollment Fee 6/18/03 100.00 100.00 Check Date Check # Payable to Total Discounts Check Amount 6/1 8/03 7358 Texas Commission on Environmental Quali $100.00 Acct #: Jun 18,2003 * * * * * * * * * * * * * ** *$100.00 One Hundred and 00 /100 Dollars Texas Commission on Environmental Quali P.O. Box 13088 Cashier's Office, MC -214 Austin, TX 7871 1 -3088 Invoice # Description Invoice Date Invoice Amount Discount Amount Paid Enrollment Fee 6/18/03 100.00 100.00 heck Date Check # Payable To Total Discounts Check Amount 6/18/03 7358 Texas Commission on Environmental Quali $100.00