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HomeMy WebLinkAboutNOI JUI,- ''8 - 03 MON 9:30 AM UK E STRATEGIES FAX NO. 27958431 P . ,r.v rvvv ay. wv ..an •r.v ivvva ya•vaauuu uaa� ovaW U, , �r.J vas it /VVL V Notice of Intent (N01) for Storm Water Discharges TCEQ arfcs Use Only - IS Associated with Construction Activity under the TPDES Permit Number: TXR15•• -• •• •• • . NO TPDES Construction General Permit (TXR750000) GIN Number: •� ^ •�•� •1 _• ••0 TC Q For help completing this application, read the 7X17150000 NO1 Instructions ' - (TCEQ-20022- lnstNCrlions), A. Construction MN Operator New DNo Change Customer Reference Number. CN — "_ __ n Name_ Dan Bcnaimo - , ._,.,._. .-., ,_._ _._. � _. � _... _ ,. Mailing Address: Ss em ro „� Au oterk Drive _- City: s ,,,,, ,__State:,, .Alp Code: f.,_ e7j,1 r Country Marling Information (if outside USA) Territory: _ ..,___Country Code: _ , Postal Codo: _ Phone Number: 1,5_7 20 23$.1225 _.. FXtensbn:.__....__. _.r __Fax Plumber: _ 1 ,,.,_ _. ... trmail Address:_elpenetmer swell.rtot " ,_ __ ___ type of Operator: NI Irxfividual © Sole Proprietorship - D.B.A. d Partnership E] corporation r] Federal Government © Stela Government Q County Government [] City Government II Othen _ _ Independent Operator? ® Yes © No Ntunber of Empluyees; J 0.20 Q 21 -IOD fl 101 250 Q 251500 _f ] 501 or higher Federal Tax ID:_ , Slate Franchise Tex ID Number: ._ , DUNS Number: B. Billing Address -' Name: Be si tMon_ - - - - -- _ . _ _ __- - Meiling Address: 4810 Tom Wooten Drive City' Austin „_ Stale .YX Zip coda: 78731 Country Maang Information (it outside USA) Territory: Country Cole:____ Postal fie :_ C. Project/ Site Information IJNew ©No Change Regulated Entity Reference Number: RN Narne :Dan Beesimon M Ai a Torn Woolen Drive T _,�_____ City; _ __ - Mailing Addrearg physlcal Address: 23 Comet) Drive Y Austin ^^ _ ._,., - Slate ;TX Zip Code: TS7�1 - -� Physical Access Des ten; No Comet rive a � M City, ;Ip_County: B os _ Zip Code; jj$4Q Location _N 1I .!9 _ t-Qrentwood Drive T __�,__ _ _ Latitude: Se • 36,' ^ N Longitude: 96 '_u ' _,a " W Degrees (•), Minutes ('), end Seconds (') - Latitude: _ -- Longitude; -_ Dscknal Fomi Standard induatriai Classification (SIC) code ; Also, describe the construction activity et this site (do not reveal fhs SIC code): Has e storm water pollution prevention plan boon prepared as epodlod in the; general 'murk (TX/1180000r/ ill Yes Li No m Estimated area of land disturbed (to the nearest acre): 8 Is the project / site located on Indian County Lands? 1J Yes IM3 No Does this project/ elte discharge storm water into a municipal separate storm sewer system (MS4)9 ®Yes No If yea, provide the name of the MS4 operator: The Ci e e Station ,_ ^^ _` _ Provide the name or segment number of the water body that receives storm water from thle project / alto: Carters Creek ^�� __ D. Contact - tf the TCEQ needs additional information regarding This application, who should be contacted? Name: Dan Bertsiimon .. „ Title: Owner ____ _ _ Phone Pho Number: (597) 73 11 -1 ,___ Extension: _ Fax Number; - _ 312 743 -8431 ___ E-mail Addrass .dbenalmonGeweii.net _ _ E. Payment information - Check / Money Order NI rnber. _ Norm on Check / Money Order; F. CertiOcalton _ _---- I certify uode rpenaltyofrewthat personnel property gather and evaluate the Information submitted. Based on my inquiry of the person or persons who manage the system, or those persons dIraclly responsbla for gathering the Information, the information submitted is to the beat of my knowledge and bepef, kue, eccumlo, and complete, I arm aware there ere efentncent penalties for submrtiing false kifOrmation, 'flooding the possiblrrty of fine and inealsonmern for knowing violation. ConsvzCtlon Site Operator Representative; Prefix: First: Middle; Last : __. Suffix' Title: _ '_ . - Slpnature: - r e , Date: 7 - 2_2 C Ir you have twos ons on how 0111 Art - °reboot the atone we :er program, please contact us at (512)239-4e71. .__. individualsareentitled to request and revtewthelrperson/1i information matte agencygathers on Ns forms, They may also have any envie 1n thek Information corrected. To review such Information, Contact us at (512) 2393282. The completed NOI must be mailed to the following address. Use the attached document lo submit the S 100 applcation lea. Please note that the NOI and application fee are submitted separately to different addressee. Texas Commission on Environmental Quality Storm Water & General Peretits Team; MC - 228 P.O. Box 13087 Austin, Texas 78711.3087 TCEO.20022 (02103) pages of x