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HomeMy WebLinkAboutNOIe of, CpG- S fW se s�PhZ. Notice of Intent (N Of) for Storm Water Dischar es 9 TCEa Office Use Only Associated with Construction Activity under the TPO Permit Number: TXR15 - • _ _••- NO V TPOES Construction General Permit (TXR1 50000) GIN Number: •- •- _ For help completing this application, read the TXR 150000 Not Instructions (TCEG- 20022- Instruchons.). A. Construction Site Operator []New No Change. Customer Reference Number: CN Name: - Mailing Address: 4490 City: 10" State: MZip Code 17Zq Country Mailing Information (if outside V ) Territory: Country ode: — Postal Code: Phone Number: �q "Iq� 1090 -17-SD Extension: — Fax Numb fig �qd --I O41 E -mail Address: Type of Operator: © Individual © Sole Proprietorship - D.B.A. JgParinership Q Corporation ❑ Federal Government State Government ❑ County Government ❑ City Government ❑ Other. Independent Operator? JR Yes © No Numberof Employees: )j 0 - 20 © 21 - 100 Q 101 - 250 Q 251 - 500 Q 501 or higher Federal Tax ID: State Fra Tax ID Number: •j��A DUNS Number: WA a. Billing Address TJ Name: ili"taGe t'6tki -• 6f=ym S ri f �y1YtP��YS . Mailing Address: a"V C"1l L Or I I Country Mailing Information (ifoutside USA) Territory. C. Project I Site Information Name r&44 "et: Mailing Address Physical Address City: r State: _MZip Code: — Country - Postal Code: -' Regulated Entily Reference Number. RN City Slate: __D� Zip Code x ounty. Vnhrrtt _-Lr7S Zip Code: - 1'7%4 K_ Location Access Descriptibrt: Latitude: 2 N Longitude:' A' W Degrees ('), Minutes ('}, and Seconds (') Latitude : Longitude:- Decimal Form Standard Industrial Classificati n (SIC) code: Also, describe the construction activity at this site (do not repeat the SIC code): nnJ e, - for � az*11 t�Q_ l_t*J 1 TltsYl Has a storm vtrater pollution prevention plan been prepared as specified in the general permit (TXR150000)? C&Yes Q No Estimated area of land disturbed (to the nearest acre): 15 Is the project / site located on Indian Country Lands? Q Yes Pa No Does this project ) site discharge storm water into a municipal separate storm sewer system (MS4)? © Yes ® No If yes, provide the name of the MS4 operator: Prov t he name o r segment number of the water body that receives storm water from this project I site: cir D. Contact - If the TCEQ needs additional information regarding this application, who should be contacted? Name: Title: �Y' Phone Number: Extension: Fax Nu r: E-mail Address: E. Payment Information - heck Money Order Numbec in 1 3 N ame o n Check I Money Order: i r4tn5 rrti i i .r t)I Certification 1 oenay under penaltyof 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 (he test of my knowledge and belief. true, accurate, and complete_ 1 am aware there are significant penalties for submitting false information. including (he possibility of fine and imprisonment for knowing violations. Construction Site Operator: t t j Prefix: Mf . First: t►1/�,Ua [l Middle: Last: vv.� Suffix: Title: On Gtr{ ?X '' l Signature: Date: If you have questions on how to Tilt out this form or about the storm wafer program, tease 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 Not must be mailed to the following address. Use the attached document to submit the $ 100 application fee. Please note that the Not and application tee are submitted sepatalely to different addresses. Texas Commission on Environmental Quality Storm Water & General Permits Tearn; MC - 228 P.O. Box 13081 Austin, Texas 78711 -3087 1 C:P0 2MI: ?? (05 /0:11 P;iilc 1 0l 1 . - T r -nn� 7 T JClta