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Home My WebLink AboutNOIE 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: •• •• •• •• •• •• •• TCEC� help completing this application, read the TXR150000 NOI Instructions (TC EQ- 20022 - Instructions). A. ConstructioR Site Operator ` NNo Change Customer Reference Number: CN (o D Z y 3 ZS$ Mailing Address: Country Mailing InPformation (if outside USA) Territory: Phone Number. lQ `tIt - ) - 7 7 /// Z Extension: '1 Add ss• s City: Q r-N 11tJ State: _DC Zip Code: 7 / 6 0 (o _Country Code: Postal Code: Fax Numb 972,2 8 oZ - 79 7 E -mai re 1 . - - Type of Operator: ❑ Individual ❑ Sole Proprietorship - D.B.A. ❑ Partnership EK Corporation ❑ Federal Government [] State Government ❑ County Government ❑ City Government ❑ Other: Independent Operator? ❑ Yes ® No Number of Employees: [] 0 -20 El 21-100 [] 101 -250 1Z 251 -500 El 501 or higher Federal Tax ID: _ `" 2 ( Franchise Tax ID Number: /?L/ Z6 a1C'O /� DUNS Number: O(o0`}ZQ,S'��i B. Billing Address Name: (2U_0. C" -♦ l,WC o =k�G Mailing Address: f • o • 13 o X. (0 - 1 `f City: a Z of l4 W State Zip Code: 7 7 oU Country Mailing Information (if outside USA) Territory: Country Code: Postal Code: C. Project 1 Site Information ENNew ❑No Change Regulated Entity Reference Number: RN Name: V�( 4 _CI L �� 11.c. 1� (�F 2. J 3 C Cu 11f5 f - 57 State: Zip Code: 778 Mailing Address: 1.1or.lE � �-- - Physical Address: 3 goo 5P�2rn, 01 /s f P I V-e City: IJrTt 5-Fgbo County: - 9 rLyA 4-_v 5 Zip Code: Location Access Description:'da ,00 r!a A-Jnr1Aw.esf of �6 9A,(Z 2v�n d S�rLrvt ittlS¢ /72f (j, e / ��r Latitude: k ° 3`) ' 00 N Latitude:_ Standard I Longitude: ° 1 W Degrees ('), Minutes ('), and Seconds ( ") Longitude: - Decimal Form Classification (SIC) code: /(o/ Also, describe the construction activity at this site (do not repeat the SIC code): N e -4,0' u -1 Al fw Su bCh U /S /'a2c - Has a storm water pollution prevention plan been prepared as specified in the general permit (TXR150000)? Wyes ❑ No Estimated area of land disturbed (to the nearest acre) Is the project I site located on Indian Country Lands? ❑ Yes rd No Does this project I site discharge storm water into a municipal separate storm sewer system (MS4)? []Yes Pq 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 I site: r _P41 I Try• 1,.. �. ,i . Contact - if,`t //he TCEQ ne ds additional information regarding this application, who should be contacted ". L_I 1< G C__ I% Name: /�Q [f �/E �5 0 Title: S /1w144 - - Phone Number: (_ -m l - 72 - 7// 2 Extension: Fax Number: 8 3 - .2 E - mail Address: - 4 14l I ' e /e►'san je )/o ctx,C041/ c{z.rc c V A - E. Payment Information - Check /(/ on umber: Name on Check I Money Order: 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 Last:_ Signa First: W, //14k4 k4 Middle: Suffix: Title: V1e F j�rl x G,/L°i1 Z' 7____�! %Z/�i" Date: _ ✓��2 3 d `f C. 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 & General Permits Team; MC - 228 P.O. Box 13087 Austin, Texas 78711 -3087 Page 1 of 2 TCEQ -20022 (05 /03) 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 Storm Water General Permit: TXR150000 Check / oney Order No D �S 1p 7 13 `/ Amount of Check/Money Order: Date of Check or Money Order: 3/ Z O � / Name on Check or Money Order: D Pf tek:6 /L J7.9 4 rl U)7 X O Facility/ Site Name: W 2 sl fl f I l ' 11 & a f - A a � I 1 Facility/ Site Physical Address: dodAwes / of l96o S�ernG�rrsf 2, � _RAXIOW 1 0. 1-t47'e ` City: �l Zip Code: 773 ` 25 08624 11 -24 Office AU # 1210(8) Operator I.D.: nwt c2200 PERSONAL MONEY ORDER FAY TO THE ORDER OF * * *TCE Q * ** ** *One hundred dollars and no cents * ** Wells Fargo Bank, N.A. 3000 BRLARCREST DR BRYAN, TX 77802 FOR INQUIRIES CALL (480) 3943122 11'08624314344 1:1 2 31000 2 1 5057331" 0862414344 March 23, 2004 * *$100.00 ** V I F ns $ 100 � Purchasels Signature TCEO -20022 (05/03) Page 2 of 2 Attachment 1 TPDES General Permit TXR150000 rwwr�t rw �rr�tr trr�r r +tir CONSTRUCTION SITE NOTICE FOR THE Texas Commission on Environmental Quality (TCEQ) Storm Water Program TPDES GENERAL PERMIT TXR150000 The following information is posted in compliance with Part H.D.I. of the TCEQ General Permit Number TXR150000 for discharges of storm water runoff from construction sites. Additional information regarding the TCEQ storm water permit program may be found on the internet at: xvuAv tnrrc date th nc/ nermittina /u 'atemermh«vnerm/tndestorm For Construction Sites Authorized Under Part H.D.1. the following certification must be completed: I /�LO /-t 4 1 t rso ✓L (Typed or Printed Name Person Completing This Cedification) certify under penalty of law that I have read and understand the eligibility requirements for claiming an authorization by waiver under Part II.D.1. of TPDES General Permit TXR150000 and agree to comply with the terms of this permit. Construction activities at this site shall occur within a time period listed in Appendix A of the TPDES general permit for this county, that period beginning on ge/,/ 2 S and ending on <r� I understand that if construction runoff activities continue past this period, all storm water must be authorized under a separate provision of this general permit. A copy of this signed notice is supplied to the operator of the MS4 if discharges enter an MS4 system. I am aware there are significant penalties for providing false information or for conducting unauthorized disc har es, including the possibility of fine and imprisonment for knowing violations. Signa e and Title Date Pace 32 ame and Phone Number: 4 )P/ l soYx N f 17 7 scription: 4 w e s 4 o f Sri 4-e �se�f �N o dress or description of the site's FOate,or 3 0 G C S� ��► vN (S Di B!'iit/Cc9�'1 �t 5 imated start date and projected end that disturbed soils will be S 4 l e. a� 17 R E c : IV A i2C E( 2 5 0 3 E v.a( D } 5 e �42wt b -� 25� Z O o 3 For Construction Sites Authorized Under Part H.D.1. the following certification must be completed: I /�LO /-t 4 1 t rso ✓L (Typed or Printed Name Person Completing This Cedification) certify under penalty of law that I have read and understand the eligibility requirements for claiming an authorization by waiver under Part II.D.1. of TPDES General Permit TXR150000 and agree to comply with the terms of this permit. Construction activities at this site shall occur within a time period listed in Appendix A of the TPDES general permit for this county, that period beginning on ge/,/ 2 S and ending on <r� I understand that if construction runoff activities continue past this period, all storm water must be authorized under a separate provision of this general permit. A copy of this signed notice is supplied to the operator of the MS4 if discharges enter an MS4 system. I am aware there are significant penalties for providing false information or for conducting unauthorized disc har es, including the possibility of fine and imprisonment for knowing violations. Signa e and Title Date Pace 32 Attachment 2 TPDES General Permit TXR150000 s w Contact Name and Phone Number: AM CONSTRUCTION SITE NOTICE FOR THE Texas Commission on Environmental Quality (TCEQ) Storm Water Program TPDES GENERAL PERMIT TXR150000 The following information is posted in compliance with Part H.D.2. of the TCEQ General Permit Number TXR150000 for discharges of storm water runoff from construction sites. Additional information regarding the TCEQ storm water permit program may be found on the intemet at: www.tnrcc. state.tx. us/ permitting /watemerm/wwuerm/tndestorm 19 For Construction Sites Authorized Under Part II.D.2. (Obtaining Authorization to Discharge) the following certification must be completed: /S e ✓t (Typed or Printed Name Person Completing This Certification) Certify under penalty of law that I have read and understand the eligibility requirements for claiming an authorization under Part II.13.2. of TPDES General Permit TXR150000 and agree to comply with the terms of this permit. A storm water pollution prevention plan has been developed and implemented according to permit requirements. A copy of this signed notice is supplied to the operator of the MS4 if discharges enter an MS4 system. I am aware there are significant penalties for providing false information or for conducting unauthorized discharges, including the possibility of fine and / imrisonment for knowing violations. Signature and Title Date Page 33 Contact Name and Phone Number: K E i7 H P' E zs o -A (T) c l) - 7 "7 4 — ll1 Z Project Description: 4t4 h ,��s (Physical address or description of the site's 3 q b U S/7 ►i / n % GY/IS !�/` �Ltlzlz�r / ocation, estimated start date and projected end ate, or date that disturbed soils will be tabilized) 5 f W rc D A +C - 4114 �r- H ZS Z Do 3 i )) A* 4 F S . e� - 8 x ja zA Z 5, Dr 5 a 13 5W rz 1,4 : /-/ A G Location of Storm Water Pollution A f - 7 - o 135 7 o /Z 6 .Sff 21 Gals Prevention Plan : d >32 mow, �X - 77U 7 19 For Construction Sites Authorized Under Part II.D.2. (Obtaining Authorization to Discharge) the following certification must be completed: /S e ✓t (Typed or Printed Name Person Completing This Certification) Certify under penalty of law that I have read and understand the eligibility requirements for claiming an authorization under Part II.13.2. of TPDES General Permit TXR150000 and agree to comply with the terms of this permit. A storm water pollution prevention plan has been developed and implemented according to permit requirements. A copy of this signed notice is supplied to the operator of the MS4 if discharges enter an MS4 system. I am aware there are significant penalties for providing false information or for conducting unauthorized discharges, including the possibility of fine and / imrisonment for knowing violations. Signature and Title Date Page 33