HomeMy WebLinkAboutNOI Notice of Intent (NOI) for Storm Water TCEQ Office Use Only
ar.r Nerd Discharges Associated with Construction TPDES Permit Number: TXR I -1 -1 -1
MKS Activity under the TPDES General Permit GIN Number: 1 1 1 1 1 1 1 1
Fee Receipt No.
KEG
IMPORTANT:
•Use the attached INSTRUCTIONS when completing this form.
•After completing this form, use the attached CUSTOMER CHECKLIST to make certain all items are complete and accurate.
•Missing, illegible, or inaccurate items may delay final acknowledgment or coverage under the general permit.
Application Fee: You must submit the $100 NOI Application Fee to TCEQ under separate cover (see instructions) using the attached Application Fee
submittal form. (DO NOT SEND A COPY OF THE NOI WITH THE APPLICATION FEE SUBMITTAL FORM)
Tell us how you paid for this fee:
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Check/Money Order No.: G L 1 5 Name Printed on Check: 'gas C >�5�is i �� t.+ �d. " v;+l'D m is; - rvi l° F' i(4L4 -0/
A. OPERATOR
1. TCEQ Issued Customer Number (CN) (if available): 601393093
2. Legal Name (spelled exactly as filed with the Texas Secretary of State, County, or legal document that was used in forming the entity):
MAIN STREET HOMES, LTD.
3. Mailing Address: 7447 BEE CAVES ROAD Suite No./Bldg.No.: SUITE 150
City: AUSTIN State: TEXAS ZIP Code: 78746
4. Phone No.: ( 512 ) 327-8620 Extension: N/A
5. FAX No. 512- 327 -5138 E -mail Address:
6. Type of Operator: 0 Individual 0 Sole Proprietorship- D.B.A. Q Partnership
0 Corporation 0 Federal Government 0 State Government
0 County Government 0 City Government 0 Other:
7. Independent Operator: !] Yes ONo (If governmental entity or a subsidiary or part of a larger corporation, check "NO ")
8. Number of Employees: 0 0 -20; D 21 -100; 0 101 -250; 0 251 -500; or 0 501 or higher
9. Business Tax and Filing Numbers (not applicable to Individuals, Government, General Partnerships, and Sole Proprietorship- D.B.A):
State Franchise Tax ID Number: N/A Federal Tax ID: 742862508
TX SOS Charter (filing) Number: N/A DUNS Number: N/A (If known)
B. BILLING ADDRESS (The Operator is responsible for paying the annual fee.)
A Same As Operator (check if address is the same, then proceed with Section C.)
1. Billing Mailing Address: Suite No./Bldg.No.:
City: State: ZIP Code:
2. Billing Contact (Attn or C /O):
3. Country Mailing Information (if outside USA) Territory: Country Code: Postal Code:
4. Phone No.: ( ) - Extension:
5. FAX No. E -mail Address:
TCEQ -20022 (07/12/2004) Page 1 of 3
C. APPLICATION CONTACT (If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: MISTI SHAFER Title: OFFICE MANAGER Company: COMPLIANCE RESOURCES, INC.
2. Phone No.: ( 512 ) 930-7733 Extension: 231
3. FAX No. 512 -864 -7629 E -mail Address: misti @complianceresourcesinc.com
D. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN) (if available):
2. Name of Projector Site: MEADOW CREEK, PHASE ONE
3. Physical Address of Project or Site: (enter in spaces below)
Street Number: N/A Street Name: N/A
City (nearest to the site): ZIP Code (nearest to the site): County (Counties if >1):
COLLEGE STATION 77845 BRAZOS
4. If no physical address (Street Number & Street Name), provide a written location access description that can be used for locating the site:
(Ex.: 2 miles west from intersection of Hwy 290 & IH35 on Hwy 290 South)
SOUTHWEST OF THE INTERSECTION OF FM 2154 (WELLBORN ROAD) AND KOPPE BRIDGE ROAD
5. Latitude: 30 °31'15" N Longitude: 096 °18'42" W
6. Standard Industrial Classification (SIC) code: 1521
7. Describe the activity related to the need for this authorization at this site (do not repeat the SIC and NAICS code):
SINGLE FAMILY RESIDENTIAL DEVELOPMENT
8. Is the project/site located on Indian Country Lands? D Yes D No
If Yes, you must obtain authorization through EPA, Region VI.
E. SITE MAILING ADDRESS (address for receiving mail at the site)
fi Same As Operator (check if address is the same, then proceed with Section F.)
Mailing Address: Suite No.BIdg.No.:
City: State: ZIP Code:
F. GENERAL CHARACTERISTICS
1. Has a Pollution Prevention Plan been prepared as required in the general permit? D Yes ® No
If No, coverage may be denied as the PPP is required at the time the NOI is submitted to TCEQ.
2. Provide the estimated area of land disturbed (to the nearest acre): 21 Acres
3. Provide the name of the receiving water body (local stream, lake, drainage ditch), MS4 Operator (if applicable) and the segment number where storm
water runoff will flow from the construction site.
MS4 Operator: Cit of College Station Receiving Water Body: PEACH CREEK Segment:
TCEQ -20022 (07/12/2004) Page 2 of 3
G. CERTIFICATION
I STEVE BARTHOLOMEW PRESIDENT
Typed or printed name Title (Required)
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. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing
violations.
I further certify that I am authorized under 30 Texas Administrative Code §305.44 to sign and submit this document, and can provide documentation
in proof of such authorization upon request.
Signature :_. — �� ._ ---"' Date:
(Use Blue Ink)
TCEQ -20022 (07/12/2004) Page 3 of 3