SWM-CS101111 (3) Wm:111 Notice of Change (NOC) to an Authorization TCEQ Office Use Only
N ' for Storm Water Discharges from Small Permit No.:
er
iromil Municipal Separate Storm Sewer Systems CN:
TCEQ (MS4) under the TPDES Phase II MS4 General
Permit (TXR040000)
* * * ** IMPORTANT * * * **
PLEASE READ THE FOLLOWING INFORMATION AND INSTRUCTIONS BEFORE FILLING OUT THIS FORM.
The form will be returned for one of the following reasons:
1) the permit number is not provided, invalid, or no longer active,
2) a wet ink signature of person meeting signatory requirements for permittee is not provided,
3) the current permittee is not the applicant, and;
4) a requested change in operator name is not a legal name change .
THIS FORM CANNOT BE USED FOR A CHANGE IN OPERATOR. REFER TO YOUR GENERAL PERMIT.
What is the Permit Number of the authorization to be changed? TXR04 0375
A. APPLICANT INFORMATION: Search Central Registry at http: / /wwwl2.tceq.state.tx.us /crpub/
1. Operator (Permittee)
a. What is the full Legal Name of the current Operator as on the authorization?
City of Coppell/ Northwest Dallas County Flood Control District (NWDCFCD)
b. What is the TCEQ Central Registry Customer Number assigned to this Operator? CN 600656649
2. Permitted Site (required)
What is the TCEQ Central Registry Regulated Entity Number assigned for this permitted site? RN 105613558
B. REQUESTED CHANGE TO PERMITTED INFORMATION
What information has changed or needs corrected?
(Check one or more of the sections being updated and enter the new information in the corresponding section of this form.)
❑ Operator Legal Name Change with Texas Secretary of State (TX SOS).
(Note: Permits are not transferable. If a change in entity has occurred, this NOC is not attainable.)
❑ Address and contact information for Operator, Billing for Annual Fee or Site Mailing Address.
❑ Site Information (Regulated Entity)
(Note: Permits under a general permit are site specific. If a change in site location has occurred, this NOC is not attainable.)
El Change To The Approved SWMP
1. OPERATOR LEGAL NAME CHANGE
a. What is the NEW active Legal Name with TX SOS or on other legal document?
New Legal Name:
b. What is the TX SOS Filing Number for us to confirm this official name change?
(This is only applicable to Limited Partnership or Corporations.)
2. ADDRESS & CONTACT INFORMATION CHANGE
a. What mailing address and/or contact information has changed? (check one or more as applicable)
Operator for permit correspondence Q Site (RE) Mailing Address and contact information
Billing address /contact for Receiving Annual Fee Statement
b. If you selected more than one, is the information to be updated the same for each selection?
❑ Yes — Provide the updated information in the fields below.
O No — Attachment 1 of the NOC is attached to this form, to provide the different addresses.
ATTN or C /O:
Address: Suite No. /Bldg. No./Mail Code:
City: State: ZIP Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
Phone No.: ( ) Ext: Fax No.: ( ) E - Mail:
TCEQ- 20392 (08/14/2007) Page 1
3. REGULATED ENTITY (RE) SITE INFORMATION CORRECTION or UPDATE
a. Updated or Corrected description of the regulated MS4 boundaries:
b. Other update to regulated entity information. Please explain.
4. CHANGE TO THE APPROVED SWMP
Check the applicable item(s) to be changed or updated and complete the section for each item. Reference the attachment for each item.
❑ Add the 7th Minimum Control Measure (MCM) to the approved SWMP.
Complete Attachment 2 of the NOC and the following question:
Are you seeking to use the 7 MCM only in the regulated (urbanized) area?
❑ Yes - Attach the MCM with Attachment 2 of the NOC.
❑ No — Attach the MCM with Attachent 2 of the NOC and indicate YES to the following certification:
I certify that the MS4 is in compliance with all of the MCMs listed in this general permit, in the MS4's additional area where the 7
MCM will be utilized. EYES
Failure to indicate YES to this certification will result in denial.
• Notice to update the approved SWMP adding components, controls, or requirements to the SWMP; or replacing a BMP with an
equivalent BMP.
Are the revisions to the approved SWMP attached? •Yes, under attachment #3
❑ Request to update the approved SWMP, replacing a less effective or infeasible BMP specifically identified in the SWMP with an
alternate BMP.
Are the revisions to the approved SWMP attached? ❑Yes, under attachment
❑ Other requested changes to the approved SWMP requiring TCEQ approval.
Are the revisions to the approved SWMP attached? ❑Yes, under attachment
C. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: Mike Garza Title: Graduate Engineer Company: City of Coppell
2. Phone No.: ( 972) 304 -7019 Ext: Fax No.: ( ) E -Mail: mgarza @coppelltx.gov
D. CERT IFICATION
Operator Certification:
I Clay Phillips City Manager
Typed or printed name (REQUIRED) 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 nroof of suc orizat'on upon request. l
Signature: `:0 � / Date:_ 2,i) he
(Use b ue ink) (REQUIRED) (REQUIRED)
TCEQ- 20392 (08/14/2007) Page 2
Attachment 1 to a NOC Form for Providing Different Address & Contact Information
Related to a Specific Permit under General Permit TXR040000
What is the Permit No.? TXR04 0375
(REQUIRED)
ADDITIONAL ADDRESS & CONTACT INFORMATION
Fill in the changes as applicable. Incomplete and invalid addresses will not be used. Verify mailing addresses at USPS.com.
Operator
ATTN or C /O:
Address: Suite No./Bldg. No. /Mail Code:
City: State: ZIP Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
Phone No.: ( ) Ext: Fax No.: ( ) E -Mail:
Billing Address for Receiving Annual Fee Statement
ATTN or C /O:
Address: Suite No. /Bldg. No. /Mail Code:
City: State: ZIP Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
Phone No.: ( ) Ext: Fax No.: ( ) E -Mail:
Site (RE) Mailing Address
ATTN or C /O:
Address: Suite No. /Bldg. No. /Mail Code:
City: State: ZIP Code:
Country Mailing Information (if outside USA). Country Code: Postal Code:
Phone No.: ( ) Ext: Fax No.: ( ) E -Mail:
TCEQ- 20392 NOC Attachment 1 (08/14/2007) Page 1
Attachment 2 to a NOC Form for adding the Optional 7 Minimum Control Measure
7 Minimum Control Measure Cover Sheet
This cover sheet MUST be completed by indicating the page number where the requested item will be
found in the MCM. Provide the page number in the left column for each item. The questions relating to
the Edwards Aquifer must also be answered.
This cover sheet MUST be attached to the front of the MCM.
Operator Name on NOI: City of Coppell/ Northwest Dallas County Flood Control District (NWDCFCD)
Page # (s) Optional 7th MCM : Municipal Construction Activities (only available within the regulated area where the MS4
operator meets the definition of construction site operator)
If this MCM is utilized applicable, SWMP must include the following information:
Description of how construction activities will generally be conducted so as to take into consideration local
conditions of weather, soils, and other site specific considerations
Description of the area that this MCM will address and where the MS4 operator's construction activities are
covered (e.g. within the boundary of the urbanized area, the corporate boundary, a special district boundary, an
extra territorial jurisdiction, or other similar jurisdictional boundary)
If the area included in this MCM includes areas outside of the UA, then all MCMs will be implemented over those
additional areas as well.
Description provided for one of the following:
► How contractor activities will be supervised or overseen to ensure that the SWP3 requirements are
properly implemented at the construction site(s); or
► How the MS4 operator will make certain that contractors have a separate authorization for storm
water discharges if needed.
General description of how a construction SWP3 will be developed for each construction site.
Edwards Aquifer Rule
Is the discharge or potential discharge from regulated construction activities within the Rechar e Zone, Contributing
Zone, or Contributing zone within the Transition zone of the Edwards Aquifer? LJYes 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 either included or referenced in the construction storm water pollution prevention
plan(s).
TCEQ- 20392 NOC Attachment 2 (08/14/2007) Page 1
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Notice of Change (NOC) to an Authorization for Storm Water Discharges from Small
Municipal Separate Storm Sewer Systems (MS4) under the TPDES Phase II MS4
General Permit (TXR040000)
General Information and Instructions
GENERAL INFORMATION
Where to - *wipe Nnti'e of Chan eg (NO � .
• REGULAR U.S. MAIL � BY OVERNIGHT /EXPRESS MAIL
Texas Commission on Environmental Quality Texas Commission on Environmental Quality
Applications Review & Processing Team (MC148) Applications Review & Processing Team (MC148)
P.O. Box 13087 12100 Park 35 Circle
Austin, TX 78711 -3087 Austin, TX 78753
TCEQ Contact list:
pp Ica it ' . : - $ re ating to the status and form requirements: 512/239 -4671
Technical Questions relating to the general permit: 512/239 -4671
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 Change Process:
When your NOC is received by the program, the form will be processed as follows:
1. Administrative Review: The form will be reviewed to ensure the request is from the permittee (operator) on the authorization, the permit is active
and initial coverage was acknowledged. Each item on the form will be reviewed for a complete response that qualifies for a NOC. In addition, the
operator's legal name change must be verified with Texas Secretary of State (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.
If an item is incomplete or not verifiable as indicated above, the operator may be notified by letter, phone call or email. In some instances as noted at the
beginning of the form, the request may simply be returned.
2. NOC Confirmation: An updated Acknowledgment Certificate will be mailed to the operator only if the NOC is to change information provided on
the acknowledgment certificate. The original coverage effective date will not change.
General Permit (Your Permit)
You may view and print your general permit on the TCEQ web site www.tceq.state.tx.us.
Enter the general permit number as the key word in the search box to locate the specific web page.
General Permit Forms
The Notice of Intent (NOI), Notice of Termination (NOT), and Notice of Change (NOC) with instructions are available in Adobe Acrobat
PDF format on the TCEQ web site www.tceq.state.tx.us.
Change in Operator
An authorization under the general permit is not transferable. If the operator 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 NOI must be submitted not later than 10 days prior to the change in
Operator status. Note that the NOT is effective on the postmarked date. It may be necessary to not terminate the existing permit until coverage by the
new entity is confirmed.
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.
You can find the information on the Central Registry web site at wwwl2.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 "Additional ID ".
The Customer (Permittee) is responsible for providing consistent information to the TCEQ, and for updating all CN and RN data for all associated
authorizations as changes occur. For General Permits, a Notice of Change form must be submitted to the program area for approval to update the CN and
RN data in central registry.
TCEQ- 20392 NOC Instructions (08/14/2007) Page 1