Fillable Notice Of Intent For Stormwater Discharge Application And Checklist PDF (City of Mansfield, Texas)

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Notice Of Intent For Stormwater Discharge Application And Checklist PDF (City of Mansfield, Texas)

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TCEQ-20022 (03/05/2008) Page 1
Notice of Intent (NOI) for Storm Water
Discharges Associated with Construction
Activity under TPDES General Permit
(TXR150000)
TCEQ Office Use Only
Permit No.: TXR15
RN:
CN:
Ref No:
Sign up now for ePermits NOI at www6.tceq.state.tx.us/steers
Get Instant Permit Coverage and only pay a $225 application fee.
If filing a paper NOI you can pay the application fee on line? Go to www.tceq.state.tx.us/epay
Select Fee Type: GENERAL PERMIT CONSTRUCTION STORM WATER DISCHARGE NOI APPLICATION
If submitting a paper NOI, coverage under the general permit starts seven (7) days after the date postmarked for delivery to
TCEQ.
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. TXR15
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.: Company Name on checking account:
EPAY: Voucher No.: Is the Payment Voucher copy attached? Yes
A. OPERATOR (applicant)
1. If the applicant is currently a customer with TCEQ, what is the Customer Number (CN) issued to this entity?
CN
(Search Central Registry)
2. What is the Legal Name of the entity (applicant) applying for this permit?
(The legal name must be spelled exactly as filed 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: Job Title:
4. What is the Operator’s (applicant) mailing address as recognized by the US Postal Service? (verify at USPS.com)
Address: Suite No./Bldg. No./Mail Code:
City: State: ZIP Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
5. Phone No.: ( )
Extension:
6. Fax No.: ( )
E-mail Address:
7. Indicate the type of Customer:
Individual Sole Proprietorship-D.B.A. Limited Partnership
Corporation Federal Government General Partnership
State Government County Government City Government
Other Government Other (describe):
Reset Form
TCEQ-20022 (03/05/2008) Page 2
8. Independent Operator: Yes No (If governmental entity, subsidiary, or part of a larger corporation, check “No”.)
9. Number of Employees: 0-20; 21-100; 101-250; 251-500; or 501 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 ( Verify the entity’s status and filing no. with TX SOS at 512/463-5555 )
State Franchise Tax ID Number: Federal Tax ID:
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: Title: Company:
2. Phone No.: ( ) Extension:
3. Fax No.: E-mail Address:
C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN): RN
(Search Central Registry)
2. Name of Project or Site (the name as known by the community where this facility/project is located):
(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 Section A for a physical address.
If No, complete Section B for site location information.
Section A: Enter the physical address for the site. (verify it with USPS.com or other delivery source)
Street Number: Street Name:
City: ZIP Code:
Section B: 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)
City where the site is located or nearest city to site:
ZIP Code where site is located:
4. Identify the county where the site is located:
5. Latitude: Longitude:
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)
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: Street Name:
City: State: ZIP Code:
D. GENERAL CHARACTERISTICS
1. Is the site located on Indian Country Lands? 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 Osha.gov)
Primary: Secondary:
TCEQ-20022 (03/05/2008) Page 3
3(a) What is the total number of acres disturbed?
3(b) Is the project site part of a larger common plan of development or sale? 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. Discharge Information (all information MUST be provided or the permit will be denied)
4(a) What is the name of the water body(s) to receive the storm water runoff or potential runoff from the site?
4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventually
reach?
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 No
If Yes, provide the name of the impaired water body(s).
4(d) Is the discharge into an MS4? Yes 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 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 Storm Water Pollution Prevention Plan.
E. CERTIFICATION
Check AYes@ to the certifications below. Failure to certify to all items will result in denial.
Yes
I certify that I have obtained a copy and understand the terms and conditions of the general permit (TXR150000).
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
I understand that a Notice of Termination (NOT) must be submitted when this authorization is no longer needed.
Yes
I certify that a storm water pollution prevention plan has been developed and implemented prior to construction,
and that is compliant with any applicable local sediment and erosion control plans and prepared and implemented
as required in the general permit TXR150000.
Operator Certification:
I,
Typed or printed name (Required & 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. 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 Checklist (03/05/2008) Page 1
Did you complete everything? Use this checklist to be sure!
Are you ready to mail your form to TCEQ? Go to the General Information Section of the Instructions for mailing addresses.
Customer GP Notice of Intent Checklist
TXR150000
/
This checklist is for use by the operator to ensure a complete application. Missing information may result in denial of coverage under the
g
permit. (See NOI Process description in the Instructions)
Application Fee of $325.00
was mailed separately to TCEQ=s Cashiers=s Office (separate from the NOI) or the EPAY payment voucher is attached.
OPERATOR INFORMATION - Confirm each item is complete:
/
Customer Number (CN) issued by TCEQ Central Registry
Legal Name as filed to do business in Texas (Call TX SOS 512/463-5555)
Name and Title of person signing the application. This person must meet signatory requirements in 30 TAC Section 305.43
Operator Mailing Address is complete & verifiable with USPS. www.usps.com
Phone Numbers/E-mail Address
Type of Operator (Entity Type)
Independent Operator
Number of Employees
For Corporations or Limited Partnerships – Tax ID and SOS Filing numbers are REQUIRED
Application Contact person we can call for questions about this application.
REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE - Confirm each item is complete:
/
Regulated Entity Reference Number (RN) (if site is already regulated by TCEQ)
Site/Project Name/Regulated Entity
Site/Project (RE) Physical Address Please do not use a rural route or post office box for a site location
Or if no physical address, the location information that includes description, zip code and city is listed.
Latitude and Longitude TCEQ USGS Topographic Map Viewer
or TerraServer-USA
Business description
Site Mailing Address (checked same as operator or complete & verifiable with USPS. www.usps.com)
GENERAL CHARACTERISTICS - Confirm each item is complete:
/
Indian Country Lands –the facility is not on Indian Country Lands
Standard Industrial Classification (SIC) code www.osha.gov/oshstats/sicser.html
Acres Disturbed is provided and qualifies for coverage through a NOI.
Common plan of development or for sale?
Discharge Information:
receiving water body
segment number(s) is REQUIRED
water body on the latest EPA-Approved Clean Water Act 303(d) list of impaired waters
MS4 Operator
Edwards Aquifer Rule
CERTIFICATION
Certification statements have been checked indicating “Yes”
Signature meets 30 Texas Administrative Code (TAC) '305.44
and is original and has been provided for the Operator.
TCEQ-20022 Instructions (03/05/2008) Page 1
Notice of Intent (NOI) for Storm Water Discharges Associated with Construction
Activity under TPDES General Permit (TXR150000)
General Information and Instructions
GENERAL INFORMATION
Where to Send the Notice of Intent (NOI) and other related forms:
BY REGULAR U.S. MAIL
Texas Commission on Environmental Quality
Storm Water Processing Center (MC228)
P.O. Box 13087
Austin, TX 78711-3087
BY OVERNIGHT/EXPRESS MAIL
Texas Commission on Environmental Quality
Storm Water Processing Center (MC228)
12100 Park 35 Circle
Austin, TX 78753
TCEQ Contact list:
Application Processing Questions relating to the status and form requirements: 512/239-3700, 512/245-0130 or swpermit@tceq.state.tx.us
Technical Questions relating to the general permit: 512/239-4671 or swgp@tceq.state.tx.us
Environmental Law Division: 512/239-0600
Records Management for obtaining copies of forms submitted to TCEQ: 512/239-0900
Information Services for obtaining reports from program data bases (as available): 512/239-DATA (3282)
Financial Administration=s Cashier=s office: 512/239-0357 or 512/239-0187
Notice of Intent Process:
When your NOI is received by the program, the form will be processed as follows:
1. Administrative Review: Each item on the form will be reviewed for a complete response. In addition, the operator=s legal name must be verified with
Texas Secretary of State as valid and active (if applicable). The address(s) on the form must be verified with the US Postal service as an address
receiving regular mail delivery. Never give an overnight/express mailing address.
2. Notice of Deficiency: If an item is incomplete or not verifiable as indicated above, a notice of deficiency (NOD) will be mailed to the operator. The
operator will have 30 days to respond to the NOD. The response will be reviewed for completeness.
3. Acknowledgment of Coverage: An Acknowledgment Certificate will be mailed to the operator. This certificate acknowledges coverage under the
general permit.
-or-
Denial of Coverage: If the application is too incomplete to process, or the operator fails to respond to the NOD or the response is inadequate,
coverage under the general permit may be denied. If coverage is denied, the operator will be notified.
General Permit (Your Permit)
If filing the NOI through ePermits online application, coverage under the general permit begins the day the NOI is submitted to TCEQ through
epermits.
Sign up now for on line NOI at https://www6.tceq.state.tx.us/steers/
If mailing a paper NOI, coverage under the general permit begins seven (7) days after a completed NOI is postmarked for delivery to the TCEQ. You
should have a copy of your general permit when submitting your application.
You may view and print your permit for which you are seeking coverage, on the TCEQ web site
http://www.tceq.state.tx.us/permitting/water_quality/stormwater/TXR15_AIR.html.
General Permit Forms
The Notice of Intent (NOI), Notice of Termination
(NOT), and Notice of Change (NOC) #20391 with instructions are available in Adobe Acrobat
PDF format on the TCEQ web site
http://www.tceq.state.tx.us/permitting/water_quality/stormwater/TXR15_AIR.html.
Sign up now for on line Notice of Termination application at https://www6.tceq.state.tx.us/steers/
Change in Operator
An authorization under the general permit is not transferable. If the operator or owner of the regulated entity changes, the present permittee must submit
a Notice of Termination and the new operator must submit a Notice of Intent. The NOT and NOI must be submitted not later than 10 days prior to the
change in Operator status.
TCEQ-20022 Instructions (03/05/2008) Page 2
TCEQ Central Registry Core Data Form
The Core Data Form has been incorporated into this form. Do not send a core data form to TCEQ.
After final acknowledgment of coverage under the general permit, the program will assign a Customer Number (CN) and Regulated Entity Number (RN).
For Construction Permits, a new RN will be assigned for each Notice of Intent filed with TCEQ, since construction project sites can overlap with other
Customers. The RN assigned to your construction project will not be assigned to any other TCEQ authorization.
You can find the information on the Central Registry web site at www4.tceq.state.tx.us/crpub
. You can search by the Regulated Entity (RN), Customer
Number (CN) or Name (Permittee), or by your permit number under the search field labeled AAdditional ID@. Capitalize all letters in the permit number.
The Customer (Permittee) is responsible for providing consistent information to the TCEQ, and for updating all CN and RN data for all authorizations as
changes occur. For General Permits, a Notice of Change form must be submitted to the program area.
Application Fees:
$225.00 application fee if submitting the NOI through ePermits.
$325.00 application fee if submitting a paper NOI for processing.
The application fee is required to be paid at the time the NOI is submitted. Failure to submit payment at the time the application is filed will cause delays
in acknowledgment or denial of coverage under the general permit.
$ Mailed Payments:
DO NOT mail your check with the original Notice of Intent application.
Use the attached Application Fee payment submittal form is mailing the payment. Do not include a copy of the NOI.
BY REGULAR U.S. MAIL BY OVERNIGHT/EXPRESS MAIL
Texas Commission on Environmental Quality Texas Commission on Environmental Quality
Financial Administration Division Financial Administration Division
Cashier=s Office, MC-214 Cashier=s Office, MC-214
P.O. Box 13088 12100 Park 35 Circle
Austin, TX 78711-3088 Austin, TX 78753
$ ePAY Electronic Payment:
Go to www.tceq.state.tx.us/epay
Select Water Quality, then select the fee category “GENERAL PERMIT CONSTRUCTION STORM WATER DISCHARGE NOI APPLICATION”.
You must include a copy of the payment voucher with your NOI. Your NOI will not be considered complete without the payment voucher.
The Annual Water Quality Fee has been consolidated into the Application Fee effective March 5, 2008. An annual fee will not be assessed and
billed to operators on 9/1/2008. This does not relieve the operator of fees due for prior fiscal year assessments.
The operator will continue to receive an invoice for payment of any past due annual fee. A 5% penalty will be assessed if the payment is received by
TCEQ after the due date. Annual fee assessments cannot be waived as long as the authorization under the general permit was active on September 1 of
the FY billed.
TCEQ-20022 Instructions (03/05/2008) Page 3
INSTRUCTIONS FOR FILLING OUT THE NOI FORM
A. OPERATOR (As defined in the general permit.)
1. TCEQ Issued Customer Number (CN)
TCEQ=s Central Registry will assign each customer a number that begins with ACN,@ followed by nine digits. This is not a permit number, registration
number, or license number.
$ If this customer has not been assigned a Customer Reference Number, leave the space for the Customer Reference Number blank.
$ If this customer has already been assigned this number, enter the operator=s Customer Reference Number in the space provided.
2. Legal Name
Provide the legal name of the facility operator, as authorized to do business in Texas. The name must be provided exactly as filed with the Texas
Secretary of State (SOS), or on other legal documents forming the entity, that is filed in the county where doing business. You may contact the SOS at
512/463-5555, or go to http://www.sos.state.tx.us/corp/contact.shtml
for more information related to filing in Texas. If filed in the county where doing
business, provide a copy of the legal documents showing the legal name.
3. Name and Title of person signing the Notice of Intent application form. Signature meets 30 Texas Administrative Code (TAC) '305.44
4. Operator Mailing Address
Provide a complete mailing address for receiving mail from the TCEQ. The address must be verifiable with the US Postal Service at www.usps.com
, for
regular mail delivery (not overnight express mail). If you find that the address is not verifiable using the USPS web search, please indicate the address is
used by the USPS for regular mail delivery.
5. Phone Number
This number should correspond to this customer=s mailing address given earlier. Enter the area code and phone number here. Leave AExtension@ blank if
this customer=s phone system lacks this feature.
6. Fax Number and E-mail Address
This number and E-mail address should correspond to operator=s mailing address provided earlier. (Optional Information)
7. Type of Entity
Check only one box that identifies the type of entity. Use the descriptions below to identify the appropriate entity type:
Individual is a customer who has not established a business, but conducts an activity that needs to be regulated by the TCEQ.
Sole ProprietorshipC D.B.A. is a customer that is owned by only one person and has not been incorporated. This business may:
$ be under the person=s name
$ have its own name (Adoing business as,@ or d.b.a.)
$ have any number of employees
Partnership is a customer that is established as a partnership as defined by the Texas Secretary of State=s Office.
Corporation the customer meets all of these conditions:
$ is a legally incorporated entity under the laws of any state or country
$ is recognized as a corporation by the Texas Secretary of State
$ has proper operating authority to operate in Texas.
Government- Federal, state, county, or city government (as appropriate)
the customer is either an agency of one of these levels of government or the governmental body itself.
Other is Estate, Trust, etc.
the customer does not fit one of the above descriptions. Enter a short description of the type of customer in the blank provided.
8. Independent Operator
Check ANo@ if this customer is a subsidiary, part of a larger company, or is a governmental entity. Otherwise, check AYes.@
9. Number of Employees
Check one box to show the number of employees for this customer=s entire company, at all locations. This is not necessarily the number of employees at
the site named in the NOI.
10. State Franchise Tax ID Number
Corporations and limited liability companies that operate in Texas are issued a franchise tax identification number. If this customer is a corporation or
limited liability company, enter this number here.
Federal Tax ID
All businesses, except for some small sole proprietors, individuals, or general partnerships should have a federal taxpayer identification number (TIN).
Enter this number here. Use no prefixes, dashes, or hyphens. Sole proprietors, individuals, or general partnerships do not need to provide a federal tax ID.
TX SOS Charter (filing) Number
Corporations and Limited Partnerships required to register with the Texas Secretary of State are issued a charter or filing number. You may obtain further
information by calling SOS at 512/463-5555 http://www.sos.state.tx.us/corp/contact.shtml
.
TCEQ-20022 Instructions (03/05/2008) Page 4
DUNS Number
Most businesses have a DUNS (Data Universal Numbering System) number issued by Dun and Bradstreet Corp. If this customer has one, enter it here.
B. Application Contact
Provide the name, title and communication information of the person that TCEQ can contact for additional information regarding this application.
If the application is missing information and there is no contact person to call, the application may be denied.
C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. Regulated Entity Reference Number (RN)
This is a number issued by TCEQ=s Central Registry to sites (a location where a regulated activity occurs) regula
ted by TCEQ. This is not a permit
number, registration number, or license number.
$ If this Regulated Entity has not been assigned a Regulated Entity Number, leave this space blank.
$ If this customer has been assigned this number, enter the operator=s Regulated Entity Number.
2. Site/Project Name/Regulated Entity
If the site is already regulated by TCEQ, use the same name as on the existing Regulated Entity Reference Number
(RN).
If new, provide the name of the site as known by the public in the area where the site is located. The name you provide on this application will be used in
the TCEQ Central Registry as the Regulated Entity.
3. Site/Project (RE) Physical Address
Section A: Enter the complete physical address of where the site is located. This must be a street number and street name for a complete physical
address. This address must be validated through US Postal Service or your local police (911 service) as a valid address. Please confirm this to be a
complete and valid address. In some rural areas, new addresses are being assigned to replace rural route addresses.
Please do not use a rural route or post office box for a site location.
Section B: If a site does not have an actual physical address that includes a street number and street name, then provide a complete written location
access description, and the zip code and city where the site is located.
For example: AThe site is located 2 miles west from intersection of Hwy 290 & IH35, located on the southwest corner of the Hwy 290 South bound lane.@
This includes authorizations for construction projects such as highways and subdivision.
4. Identify the County where the site is located. If the site covers more than one county, provide the county that is most affected by the authorized
activity and list the additional county(s) as secondary.
5. Latitude and Longitude
Enter the latitude and longitude of the site in either degrees, minutes, and seconds or decimal form. For help obtaining the latitude and longitude, go to:
TCEQ USGS Topographic Map Viewer or TerraServer-USA
6. Description of Activity Regulated
In your own words, briefly describe the primary business being conducted at the site. (A description specific to what you are doing that requires this
authorization - Do not repeat the SIC Code(s).)
SITE MAILING ADDRESS
Provide a complete mailing address to be used by TCEQ for receiving mail at the site. In most cases, the address is the same as the operator. If so,
simply place a check mark in the box. If you provide a different address, please verify the address with USPS as instructed above for the operator
address.
D. GENERAL CHARACTERISTICS
1. Indian Country Lands
If your site is located on Indian Country Lands, the TCEQ does not have authority to process your application. You must obtain authorization through
EPA, Region VI, Dallas. Do not submit this form to TCEQ.
Indian Country means (1) all land within the limits of any American Indian reservation under the jurisdiction of the U.S. government, notwithstanding the
issuance of any patent, and including rights-of-way running throughout the reservation; (2) all dependent Indian communities within the borders of the
United States whether within the original or subsequently acquired territory thereof, and whether within or outside the limits of a State; and (3) all Indian
allotments, the Indian titles which have not been extinguished, including rights-of-way running through the same.
Indian Tribe means any Indian Tribe, band, nation, or community recognized by the Secretary of the Interior and exercising substantial governmental
duties and powers.
2. Standard Industrial Classification (SIC) code
Provide the SIC code that best describes the construction activity being conducted at the site.
Common SIC Codes related to construction activities include: 1521 Construction of Single Family Homes; 1522 Construction of Residential Bldgs.
Other than Single Family Homes; 1541 Construction of Industrial Bldgs. and Warehouses; 1542 Construction of Non-residential Bldgs. other than
Industrial Bldgs. and Warehouses; 1611 Highway & Street Construction, except Highway Construction; 1622 Bridge, Tunnel, & Elevated Highway
Construction; 1623 Water, Sewer, Pipeline & Communications, and Power Line Construction. For help with SIC codes, go to:
www.osha.gov/oshstats/sicser.html
TCEQ-20022 Instructions (03/05/2008) Page 5
3. Estimated Area of Land Disturbed
3(a). Provide the approximate number of acres that the construction site will disturb.
3(b). Indicate is the site is part of a common plan of development or for sale.
Construction activities that disturb less than one acre, unless they are part of a larger common plan that disturbs more than one acre, do not require permit
coverage.
Construction activities that disturb between one and five acre, unless they are part of a common plan that disturbs five acres or more acres, do not require
submission of an NOI. Therefore, the estimated area of land disturbed should not be less than five, unless the project is part of a larger common plan that
disturbs five or more acres.
ADisturb@ means any clearing, grading, excavating, or other similar activities. If you have any questions about this item, please call the storm water
technical staff at (512)239-4671.
4. Discharge Information
4 (a). The storm water may be discharged directly to a receiving stream or through a MS4* from your site. It eventually reaches a receiving water body
such as a local stream or lake, possibly via a drainage ditch. You must provide the name of the water body that receives the discharge from the site (a
local stream or lake).
4 (b). The classified segment number(s) is REQUIRED to get coverage. Go to the link to find the segment number of the classified water body where
storm water will flow http://www.tceq.state.tx.us/compliance/monitoring/water/quality/data/wqm/viewer/viewer.html
. Call Water Quality Assessments
at 512/239-4671 for further assistance. Another source for segments is: http://www.tceq.state.tx.us/comm_exec/forms_pubs/pubs/gi/gi-316/index.html
4 (c). If any surface water body(s) receiving discharges from the construction site are on the latest EPA-approved CWA § 303(d) list of impaired waters,
provide the name(s) of the water body(s).
EPA approved CWA 303d list of impaired waters can be found at: Texas Water Quality Inventory and 303(d) List - Texas Commission on Environmental
Quality - www.tceq.state.tx.us
4 (d). Identify the MS4* Operator name if the storm water discharge is into an MS4.
*MS4 is an acronym for Municipal separate storm sewer system. MS4 is defined as a separate storm sewer system owned or operated by a state,
city, town, county, district, association, or other public body (created by or pursuant to state law) having jurisdiction over disposal of sewage, industrial
wastes, storm water, or other wastes, including special districts under state law such as a sewer district, flood control or drainage district, or similar entity,
or an Indian tribe or an authorized Indian tribal organization, that discharges to water in the state.
For assistance, you may call the technical staff of the Water Quality Assessment & Standards Section at 512/239-4671.
4 (e). Edwards Aquifer Rule
See maps on the TCEQ website to determine if the site is located within the Recharge Zone, Contributing Zone, or Contributing Zone within the
Transition Zone of the Edwards Aquifer at http://www.tceq.state.tx.us/compliance/field_ops/eapp/viewer.html.
If the discharge or potential discharge is within the Recharge Zone, Contributing Zone, or Contributing Zone within the Transition Zone of the Edwards
Aquifer, a site specific authorization approved by the Executive Director under the Edwards Aquifer Protection Program (30 TAC Chapter 213) is
required before construction can begin.
The general permit requires the approved Contributing Zone Plan or Water Pollution Abatement Plan to be included as a part of the Storm Water
Pollution Prevention Plan. The certification must be answered “Yes” for coverage under the general permit.
E. CERTIFICATIONS
Failure to indicate AYes@ to ALL of the certification items may result in denial of coverage under the general permit.
The certification must bear an original signature of a person meeting the signatory requirements specified under 30 Texas Administrative Code '305.44
IF YOU ARE A CORPORATION:
The regulation that controls who may sign an NOI or similar form is 30 Texas Administrative Code §305.44(a)(1) (see below). According to
this code provision, any corporate representative may sign an NOI or similar form so long as the authority to sign such a document has been delegated to
that person in accordance with corporate procedures. By signing the NOI or similar form, you are certifying that such authority has been delegated to
you. The TCEQ may request documentation evidencing such authority.
IF YOU ARE A MUNICIPALITY OR OTHER GOVERNMENT ENTITY:
The regulation that controls who may sign an NOI or similar form is 30 Texas Administrative Code §305.44(a)(3) (see below). According to
this code provision, only a ranking elected official or principal executive officer may sign an NOI or similar form. Persons such as the City Mayor or
County Commissioner will be considered ranking elected officials. In order to identify the principal executive officer of your government entity, it may
be beneficial to consult your city charter, county or city ordinances, or the Texas statute(s) under which your government entity was formed. An NOI or
TCEQ-20022 Instructions (03/05/2008) Page 6
similar document that is signed by a government official who is not a ranking elected official or principal executive officer does not conform to
§305.44(a)(3). The signatory requirement may not be delegated to a government representative other than those identified in the regulation. By signing
the NOI or similar form, you are certifying that you are either a ranking elected official or principal executive officer as required by the administrative
code. Documentation demonstrating your position as a ranking elected official or principal executive officer may be requested by the TCEQ.
If you have any questions or need additional information concerning the signatory requirements discussed above, please contact the Texas Commission
on Environmental Quality’s Environmental Law Division at 512/239-0600.
30 Texas Administrative Code
§305.44. Signatories to Applications.
(a) All applications shall be signed as follows.
(1) For a corporation, the application shall be signed by a responsible corporate officer. For purposes of this paragraph, a responsible
corporate officer means a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other
person who performs similar policy or decision-making functions for the corporation; or the manager of one or more manufacturing, production, or
operating facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million (in second-quarter 1980
dollars), if authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures. Corporate procedures
governing authority to sign permit or post-closure order applications may provide for assignment or delegation to applicable corporate positions rather
than to specific individuals.
(2) For a partnership or sole proprietorship, the application shall be signed by a general partner or the proprietor, respectively.
(3) For a municipality, state, federal, or other public agency, the application shall be signed by either a principal executive officer or a
ranking elected official. For purposes of this paragraph, a principal executive officer of a federal agency includes the chief executive officer of the
agency, or a senior executive officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., regional
administrator of the EPA).
TCEQ-20134 (3/05/2008) Page 1
Texas Commission on Environmental Quality
General Permit Payment Submittal Form
$325 for a paper Construction NOI Application Fee
Use this form to submit your Application Fee only if you are mailing your payment.
$Complete items 1 through 5 below:
$Staple your check in the space provided at the bottom of this document.
$Do not mail this form with your NOI form.
$Do not mail this form to the same address as your NOI.
Mail this form and your check to:
BY REGULAR U.S. MAIL
Texas Commission on Environmental Quality
Financial Administration Division
Cashier=s Office, MC-214
P.O. Box 13088
Austin, TX 78711-3088
BY OVERNIGHT/EXPRESS MAIL
Texas Commission on Environmental Quality
Financial Administration Division
Cashier=s Office, MC-214
12100 Park 35 Circle
Austin, TX 78753
Fee Code: GPA General Permit: TXR150000
1. Check / Money Order No:
2. Amount of Check/Money Order:
3. Date of Check or Money Order:
4. Name on Check or Money Order:
5. NOI INFORMATION
If the check is for more than one NOI, list each Project/Site (RE) Name and Physical Address exactly as provided on the NOI. DO NOT SUBMIT
A COPY OF THE NOI WITH THIS FORM AS IT COULD CAUSE DUPLICATE PERMIT ENTRIES.
See Attached List of Sites (If more space is needed, you may attach a list.)
Project/Site (RE) Name:
Project/Site (RE) Physical Address:
Staple Check In This Space
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Notice Of Intent For Stormwater Discharge Application And Checklist PDF (City of Mansfield, Texas)

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Completed 14 July 2020

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