HomeMy WebLinkAboutNOINotice 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: •_ •� •_ _•_
Trr For help completing this application, read the TXR150000 NOI Instructions
MOW (TC EQ- 20022 - Instructions).
A. Construction Site Operat r New ❑No Change Customer Reference Number. CN
Name: z� nit /"/o
Mailing Address: City: ire a, State,&Zip Code:
Country Maili/�� Inf rmation (if outside USA ^ � Territory: Country Code: Postal Code:
Phone Numtlef 7 � ��K� 1 1 d Extension: Fax Number:
E -mail Address:
Type of Operator: ❑ Individual ❑ Sole Proprietorship - D.B.A. ❑ Partnership rporation ❑ Federal Government
❑ State Government ❑ County Government ❑ City Government ❑ Other:
Independent Operator? es ❑ No Number of Employees: 20 ❑ 21 -100 ❑ 101 -250 [:1251-500 ❑ 501 or higher
Federal Tax ID.2 4 Z o 5 1 0, ( State Franchise Tax ID Number: DUNS Number:
S. Billing Address
Name: (JCS 1�P C cT h 5 k
Mailing Address: d o' r�'� �/ i J c h/ % City: [�rf State��Zip Coder ' cr
Co untry Mailing Informati (if out side US A) T Country Code: Postal Code:
C. Project / Site Information ❑New ❑No Change Regulated Entity Reference Number: RN
Name: C r r 1 T. t r2 (-j t `t_ DEV EIS F' M E &L
Mailing Address: City: State:_ Zip Code:
Physical Address: 1 Q2aI ,,9. '7 ` t.j. vt SE �fl? A J 6 City: e. n County: — 'P5Cd?-o5 Zip Code
Location Access Description: 6Arne
Latitude: �> " N Longitude:* ' ZU " W Degrees (•), Minutes ('), and Seconds ( ")
Latitude: Longitude: — Decimal Form
Standard Industrial Classification (SIC) code: Also, describe the construction activity at this site (do not repeat the SIC code):
Uear r a ( 6- mu.v-)�a1"A . r' & & v-" e- Qvid road LLC=6c.0
Has a storm wafer pollution prevention plan been prepared as specified in the general permit (TXR150000)? VYes ❑ No
Estimated area of land disturbed (to the nearest acre): '31 Is the project / site located on Indian Country Lands? 0 Yes X No
Does this project / site discharge storm water into a municipal separate storm sewer system (MS4)? ❑ Yes NJ No
If yes, provide the name of the M94 operator.
Provide the name or segment number of the water body that receives storm water from this project/ site: F�£E �2EEIC 7� tguTp il?y
D. Contact - If the TCEQ needs additional information regarding this application, who should be contacted? "
Name: Q01A Lt> 61ArL2c- -� - Eu4ttiJF_EO. I tfe `7 C) WAJ E ie-
Phone Number: �3. �? t3 2-4, xtension: Fax Number: ('?7':�) 3094
E -mail Address. Y i�: "`
E Payment Information - Check / Money Orrier Number 7 t /`" Name on Check/ 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 property 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 Representative: t 1
Prefix: on
_ J_.1 4r• First 20i'la `U Middle: Dean
Last: G Suffix: Title: rf Z
✓tGJ i I) r°�' 1 �A
Signature: Date: 4C " Z X- D
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 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 $100
application fee. Please note that the NOI and application fee are submitted separately to different addresses.
Texas Commission on Environmental Quality
Storm Water & General Permits Team; MC - 228
P.O. Box 13087
Austin, Texas 78711 -3087
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Texas Commission on Environmental Quality
Payment Submittal Form
The storm water application fee shall be sent under separate cover to the Texas Commission on
Environmental Quality. ,
This form must be used to submit your Storm Water Application Fee. Lease complete the following
information, staple your check in the space provided at the bottom of this document, and mail it to:
Off REQULAR U.S, MAIL
Texas Commission on Environmental Quality
Financial Administration Division
Cashier's Otflce, MC -214
P.O. Box 13088
Austin, TX 78711 -3088
BY OVERNIGHT /EXPRg$,S MAIL
M.
Texas Commission on Environmental Quality
Financial Administration Division
Cashier's Office, MC -214
12100 Park 35 Circle
Austin, TX 78753
Fee Code: CQA Storm Water General Permit: �QQ00
�� l � (�
Check /Money Order Na: Amount of Check/Money Order:
Date of Check or Money Order:.._,_ ' U
Name on Check or Money Order:
Facility / Site Name:
L-
��
Facility / Site Physical Address: _ - , A , Q and, fAA ( y P"s
City: ����4� zip Code:
CENTURY IHLL LTD
PO BOX 3189 10
BRYAN TEXAS 77805
88 -381 /1119
DATE !r
If Pay to th
Order of
e C4 00, E 771
FOR
TCEO -20022 (02/03) Page 2 of 2
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