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HomeMy WebLinkAboutNOINotice of Intent (NOI) for Storm Water Discharges TCEQ Office Use Only F s Associated with Construction Activity under the TPDES Permit Number: TXR15•- •- •� •_• NO TPDES Construction General Permit (TXR150000) GIN Number: •� •� •_•_•� •� •� •• 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: bw- C LL y j-L.G Mailing Address: ?OqO ©� USCG RZO. City: BayAtJ State:XZip Code Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: Phone Number: 20 Extension: Fax Number: G&OA -6 E -mail Address: Ork° S+GtrC h b Q ao L.. cc M Type of Operator: ❑ Individual ❑ Sole Proprietorship - D.B.A` J@ Partnership ❑ Corporation ❑ Federal Government ❑ State Government ❑ County Government ❑ City Government ❑ Other: Independent operator? Yes ❑ No Number of Employees: 0-20 ❑ 21 -100 [1101-250 ❑ 251 -500 ❑ 501 or higher Federal Tax ID4M 4Z agR4State Franch Tax ID Number: DUNS Number: B. Billing Address Name: �ZCQ081R -T CA-( Mailing Address: ZptV d) L4:> f?ZL.I At , XE 1?4; • City: _A&L'fm — State: 7A Zip Code - 7 1 7$Og Cou ntry M ailing Information (if outside USA) Territory: Country Code: Postal Code: C. Project I Site Information - New ❑No Change Regulated Entity Reference Number: RN Name: �=OV - �GjQtil D1 VI 5- 1V AJ Mailing Address: 7 OQ y C L-12 ReLA AISiS& lD City. R.YAIJ State Zip Code: Physical Address: NA City: County: -- Zip Code: Location Access D escriptionT M . 2I UXUIPcal AD) 4& SIDC 0 2VrV ` r-T. 5«7'1' A (F Cf2dE 4W 20 Latitude. °,1 ' Lb " N Longitude' ° �' �" W Degrees ( °), Minutes ('), and Seconds ( ") Latitude: Longitude: Decimal Form Standard Industrial Classification (SIC) code: IG22.1 Also, describe the construction activity at this site (do not repeat the SIC code): f,EStoe7 -5t N btu t L J F-cKkw e DE- of tOP yAGr WT Has a storm water pollution prevention plan been prepared as specified in the general permit (TXR150000)7.'®Yes ❑ No Estimated area of land disturbed (to the nearest acre): I5 . c) Is the project I site located on Indian Country Lands? ❑ YesI J No Does this project I site discharge storm water into a municipal separate storm sewer system (MS4) ?'S Yes ❑ No If yes, provide the name of the MS4 operator. Gl i GF Ce lte-&-E STAT( N Provide the name or segment number of the water body that receives storm water from this project I site: +Hoer -.S GP.--w_ D. Contact - If the TCEQ needs additional information regarding this application, who should be contacted? Name: Title: U G� LfJE Phone Number: C1 178 '2.D28 Extension: Fax Number: E -mail Address: lcn c S TA a G(n 1 G 0,0 i • 1 'O I.tn E. Payment Information - Che ck I M Order Number ame on Check I Money Order: "?a 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. 1 am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Construction Site Ope ratdFP Prefix: First: .. Middle: �. La Title: Signatur Date: & Z3 '?y 3 If you have q . ns on how to fill out this form or about the storm water program, please contact us at (512) 239-4671. Individuals a titled 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 i, 1 , \ P.O. Box 13087 "t ` Austin, Texas 78 TCEQ -20022 (05/03) "- • O V Page 1 of 2 C DV- t)3- �'r )