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TCEQTCEQ Office Use Only n • Notice of Intent (NOi) for Storm Water Discharges As8ociated with Construction Activity under the TPDES Construction General Permit (TXR150000) TPDES Permit Number. TXR15•:._•:._•:._•:._• ... NO GIN Number: •:._•:._•:._•:._•:._•:._•:._•• For help oompletlng this application, 19ad the TXR150000 NOi Instructions (TCEQ-20022-lnstructions). A. Construction Site Operator i:]New []No Change Name:~ !5GHl~1 Bze"~. Mailing Addr&!ls: '21c>'$iti;ffir;g !EQ; Customer Reference Number: CN sc-~ 't:EEal.. ce12.e ------ -Clt;'Si2>"iAIJ State:1$0Zip Code:11 f)O'z; Country MaiHng Information (ifoutsid6 USA) Temtory:, _______ country Code: _____ ~Postal Code: __ _ Phone Number:efJ "f J1b $&I Extension: Fax Number:4'1 q 11f) "Ll 74 E-mail Address: ___________________________________ _ Type of Operator: D Individual D Sole Proprietorship -O.B.A. D PartnershiP"E] Corporation D Federal Government D State Government D County Government D City Government D Other: ________________ _ Independent Operator?~ Yes D No NIA'llber of Employees:"E] 0-20 D 2MOO D 101-250 D 251-500 D 501 or higher Federal Tax ID:J4 'Zf46e>G4 State Franchise Tax ID Number: DUNS Number: Country Mailing Information (if outsid6 USA) Territory: Country Code: Postal Code: C. Project I Site Information ""E]New 0No Change Regulated Entity Reference Number: RN _______ _ Name: EM~ fi?rzesr Ptf~ eLeV6~ 1i !+. c Mailing Address:"'""""';....;;A'-'--------------...-.,..,. Physical Address:~~~--...._.:.._ _______ __ Location Access Description: Latitude~ ·~ 14.1 • N Has a storm water pollution prevention plan been prepared as specified in the general permit (TXR150000)?~Yes D No Estimated area of land disturbed (to the nearest acre): \~ Is the project I site located on Indian Country Lands? D Yes S No Does this project I site discharge storm water into ,a municipal separate storm sewer system (MS4 )1'E] Yes D No If yes, provide the name of the MS4 operator:...;::Ci=•~t--,...~--.a.La-...___.-.-:....a....;i....-.""""'"--~----=-----­ Provide the name or segment number of the water body that receives storm water from this project I site: NameRAt..\ ~,rtl e!--ftl2,. TIUe:m <OflVI 1 ~ Gz?eer-D. Contact -If the T::-° needs edditional information regarding this applica~should be const:d? n Phone Number: ~11 )1S 9 S l I Extension: Fax Number: ;q3jt£ 'U J l/' E-mail Address: E. Payment lnfonnatlon -Check I Money Order Number: Name on Check I Money Order: F. Certification I oertify under peoalty of law that this document was prepantd under my direction or supervialon in accoroance with a system designed to aasul9 that quallfted pe111011nel property gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly reeponslble for gathering the Information, the Information submitted Is, ID the best of my knowledge and bellef, true, accurate, and oomplete. I am aware there ere significant penalties for submitting falae information, including the possibility of fine and imprisonment for knowing violations. Conalructlon Sim Ope tor: If you have que&tlona on how to fill out this form or about stonn water program, please oontact us at (512) 239-4671. lndlvlduals a19 entitled to request and review their personal Information that the agency gather& on Its form&. They may also have any errors in their Information oorrected. To review such information, contact us at (512) 239.3282. TCEQ-20022 (06/03) The completed NOi muat be malled lo the following eddreas. Use the attached document to submit the $100 application fee. Please note that the NOi and application fee are submitted separately to different eddresaes. Tex.-Commlaslon on Environmental Quality Stonn Wamr & General Permits Team; MC -228 P.O. Box 13087 Austin, Texas 78711-3087 Page1 of2 J Texas Commission on E"vlronmental 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. Please complete the following Information, staple your. check In the space provided at the bottom of this document, and maU It lo: ' BY REGULAR U.S. MAIL TeX81 Commlulon on Environmental Quality Flnanclal Administration Division Cslhler's Otlk:e, MC-214 P.O. Box 13088 Austin, TX 78711-3088 Fee Code:~ Check I Money Order No: 5.ft/J ' Date of Check or Money Order: t1h:J} 0~ ' BY OVERNIGHT/EXPRESS MAIL ,, TeX81 Commilllon on Environmental Quality Financial Administration Dlvlllon Cashier's Olllce, MC-214 12100 Park 35 Circle Austin, TX 78753 {~ . I .;'. s,'°"" W8'.er General Permit IXB150000 !"-~! r1 . ·.. . 'I o<> .. , ~nt ot Check/Money Order: loo a. I Name on Check or Money Order: ~ l € t ~ ly Q, OY f Facility / s1ta Name: liMEMu? fdlas=r PttASI? a.E\JeN S I(. C Facility / Site Physical Address~ AfpoMtJ.ox Q(t."' '~ 1 Sourt-\ Cf-~~ 'fal.GS1 J City. Clol!CfF Slt.Ttl1n ZlpCodo:_1 ...... 7 .... ~~s ____ _ ··-····-····------------------ TCEQ-20022 (05/03) Page2of2