HomeMy WebLinkAboutNOI TCEQ Office Use Only
Notice of Intent (NOI) for Stormwater Permit No.: TXR15
Discharges Associated with Construction RN:
Activity under TPDES General Permit CN:
�• (TXRI 50000) Ref No:
Sign up now for ePermits NOI at httus: / /www6.tcea.state.tx.us /steers/
Get Instant Permit Coverage and only pay a $225 application fee.
:o. If filing a paper NOI you can pay the application fee on line? Go to https : / /www6.tceq.texas.gov /epay/
IMPORTANT:
•Use the INSTRUCTIONS to fill out each question in this form.
•Use the attached CUSTOMER CHECKLIST to make certain all you filled out all required information.
•Incomplete applications WILL delay approval or result in automatic Denial.
Renewal of General Permit
Is this NOI to renew an ACTIVE permit?
Yes - What is your permit number? Permit No. TXRI5 0000
No - a permit number will be issued.
Application Fee if mailing a paper NOI:
You must pay the $325 Application Fee to TCEQ for the application to be considered complete.
Payment and NOI must be mailed to separate addresses. See instructions for correct mailing addresses.
Provide your payment information below, for us to verify payment of the application fee:
Mailed: Check/Money Order No.: 15 Company Name on checking account:
EPAY: Voucher No.: Is the Payment Voucher copy attached? Yes
A. OPERATOR (applicant)
I. If the applicant is currently a customer with TCEQ, what is the Customer Number (CN) issued to this entity?
CN 601598733 (Search Central Reeistrv)
2. What is the Legal Name of the entity (applicant) applying for this permit?
B.V.S. Construction Inc.
(The legal name must be spelled exactly as f fled with the Texas Secretary of State. County, or in the legal document forming the entity)
3. What is the name and title of the person signing the application?
(The person must be an official meeting signatory requirements in TAC 305.43(a).)
Name: Elaine Palasota I Title: President
4. What is the Operator's (applicant) mailing address as recognized by the US Postal Service? (verify at USPS.com)
Address: P 0. Box 985 1 Suite No./Bldg. No./Mail Code:
City: Bryan 1 state:Tx I ZIP Code: 77806
Country Mailing information (if outside USA). Country Code: Postal Code:
5. Phone No.: (979 ) 846 -3136 Extension:
6. Fax No.: ( 979) 846 -3159 E -mail Address: ela bvsine.biz
7. Indicate the type of Customer:
❑ Individual ❑Sole Proprietorship- D.B.A. ❑Limited Partnership
0 Corporation ❑Federal Government 3eneral Partnership
State Government ❑County Government ity Government
er Government ❑ Other (describe):
TCEQ -20022 (03/05/2008) Page 1
8. Independent Operator: El Yes ❑No (If governmental entity, subsidiary, or part of a larger corporation, check "No ".)
9. Number of Employees: 00 El 21 -100; 0101 -250; 0251 -500; or 0501 or higher
10. Customer Business Tax and Filing Numbers (This item is not applicable to Individuals. Government. GP or Sole Proprietor.)
REQUIRED for Corporations and Limited Partnerships ( Vcrif) the entity's status and filing no. with TX SOS at 512/463 -5555 )
State Franchise Tax ID Number: Federal Tax ID: 264473504
TX SOS Charter (filing) Number: DUNS Number (if known):
B. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: Elaine Palasota I Title: President Company: B.V.S. Construction Inc.
2. Phone No.: ( 979 ) 846 -3136 Extension:
3. Fax No.: 979 846 -3159 E -mail Address: elaine @ bvsinc.biz
C. ; REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN): RN 103062139
(Search Central Registry)
2. Name of Project or Site (the name as known by the community where this facility /project is located):
Caprock Crossing Infrastructure Improvements
(example: phase and name of subdivision or name of project that's unique to the site)
3. Does the site have a physical address?
If Yes, complete WIl for a physical address.
If No, complete ettfn� for site location information.
Sertjgj Enter the physical address for the site (Verify it with t USPS.com or other deliver;! source)
Street Number: Street Name:
City: ZIP Code:
Sectiott¢ Enter the site location information.
If no physical address (Street Number & Street Name), provide a written location access description to the site:
(Ex.: phase 1 of Woodland subdivision located 2 miles west from intersection of Hwy 290 & IH35 accessible on Hwy 290 South)
Southwest corner of State Highway 40 and State Highway 6
City where the site is located or nearest city to site: ZIP Code where site is located:
College Station Texas 77845
4. Identify the county where the site is located: Brazos
5. Latitude: 30 33' 30" I Longitude: 96 15' 31n
6. What is the primary business of this entity? In your own words, briefly describe the primary business of the Regulated Entity:
(Do not repeat the SIC and NAICS code) Construction
7. What is the mailing address for the regulated entity?
Is the RE mailing address the same as the Operator? ® Yes, address is the same as Operator ❑No, provide the address
Street Number: I Street Name:
City: I State: I ZIP Code:
D. GENERAL CHARACTERISTICS
1. Is the site located on Indian Country Lands? n No [Yes — If Yes, do not submit this NOI. Contact EPA, Region VI
If the site is on Indian country lands, you must obtain authorization through EPA, Region VI.
2. What is the Standard Industrial Classification (SIC) code (see instructions for common codes): (Search Osita.trov)
Primary: 615 Secondary:
TCEQ -20022 (03/05/2008) Page 2
3(a) What is the total number of acres disturbed? 21
3(b) Is the project site part of a larger common plan of development or sale? fl Yes ❑No
If Yes, the total number of acres disturbed can be less than 5 acres.
If No, the total number of acres disturbed must be 5 or more. If the total number of acres disturbed is less than 5 then the
project site does not qualify for coverage through this Notice of Intent. Coverage will be denied. See the requirements in the
general permit for small construction sites.
4. Ilsehiarge In rmaflon (all li nformation MUST be provided off the permit will be denied] �.
t` "k ".,7.
4(a) What is the name of the water body(s) to receive the stormwater runoff or potential runoff from the site?
Alum Creek to Navasota River
4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventually
reach? 1209
4(c) Are any of the surface water bodies receiving discharges from the construction site on the latest EPA- approved CWA
303(d) list of impaired waters?
❑ Yes GI No
If Yes, provide the name of the impaired water body(s).,
4(d) Is the discharge into an MS4? ❑Yes n No
If Yes, what is the name of the MS4 Operator?
Note: The general permit requires you to send a copy of the NOI to the MS4 Operator.
4(e) Is the discharge or potential discharge within the Recharge Zone, Contributing Zone, or Contributing Zone within the
Transition Zone of the Edwards Aquifer?
[] Yes D No
If the answer is Yes, please note that a copy of the agency approved Plan required by the Edwards Aquifer Rule (30 TAC Chapter 213) must
be included or referenced in the Stormwater Pollution Prevention Plan.
E. CERT IFICATION
Check "Yes" to the certifications below. Failure to certify to all items will result in denial.
0 Yes I certify that I have obtained a copy and understand the terms and conditions of the general permit (TXR1500001.
Yes I certify that the full legal name of the entity (Operator) applying for this permit has been provided and is legally
authorized to do business in Texas.
Yes 1 understand that a Notice of Termination (NOT) must be submitted when this authorization is no longer needed.
0 Yes I certify that a stormwater pollution prevention plan has been developed and will be implemented prior to
construction, and that is compliant with any applicable local sediment and erosion control plans,
as required in the general permit TXRI50000.
Operator Certification:
1 EkaAne Va\uso-t Vre5'1(Xe+n
Typed or printed name (Required di must be legible) Title (Required & legible)
certify under penalty of law that this document and all attachments were 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.
1 further certify that 1 am authorized under 30 Texas Ad min istratit e (*ode 4305.44 to sign and submit this document, and can provide documentation in
proof of such authorization upon request.
Signature: act * Ck � C..w' u ` Date: v
(Use blue ink)
TCEQ -20022 (03/05/2008) Page 3