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Park West CC(07.2)-PT111021 Owner's NOI pt;1 TCEQ Office Use Only r ill Notice of Intent (NOI) for Storm Water Permit No.: TXR15 MAP Discharges Associated with Construction RN: ark Activity under TPDES General Permit CN: TCEQ (TXR150000) Ref No: Sign up now for ePermits NOI at __w1w9,y6.tceg iale.lN.us /steers _ __ _ Get Instant Permit Coverage and only pay a S225 application fee. ... ' nailing a paper NOI you can pay the application fee on line? Go to %+ww.tceustate.ts.us /euav •'• Select Fee Type: GENERAL PERMIT CONSTRUCTION STORM WATER DISCHARGE NOI APPLICATION 1 f ,uirmittin;v, a paper NO I, 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 El No 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.: t- S - 1 Company Name on checking account: 4 C J EPAY: Voucher No.: Is the Payment Voucher copy attached? Yes A. OPE TOR (applicant) 1. If the applicant is currently a customer with TCEQ, what is the Customer Number (CN) issued to this entity? CN 2. What is the Legal Name of the entity (applicant) applying for this permit? Lanvera Group, Inc. (The legal name must be spelled exactly as filed with the Texas Secretory of State, County, or in the legal document fanning the entity.) 3. What is the name and title of the person signing the application? (The person must be an official meeting signato tt 'rements in TAC 305.43(a).) Name: W I lob TitlW tq - 4. What is t perator's (applicant) mailingss as recognized by the US Postal Service? - - Address: 13755 Hutton Dr, Ste 100 I Suite No.Bldg. No./Mail Code: City: Dallas I State: TX I ZIP Code: 75234 Country Mailing Information (if outside USA). Country Code: Postal Code: 5. Phone No.: 972.488.6403 Extension: 6. Fax No.: 972.488.6463 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) TCEQ -20022 (03/05/2008) Pap 1 Owner's NOI pk2 8. Independent Operator. 0 Yes ® No No (If governmental entity, subsidiary, or part of a larger corporation, check "No ".) 9. Number of Employees: is 0.20 p 21 -100 ❑ 101 -250 0251 -500 0501 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 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: NOI Processor I Title: I Company: Lanvera Group, Inc. 2. Phone No.: 972.488.6403 Extension: 3. Fax No.: 972.488.6463 E -mail Address: C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE 1. TCEQ Issued RE Reference Number (RN): RN 2. Name of Project or Site (the name as known by the community where this facility/project is located): Lanvera (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. Street Number. 112 Street Name: Wrangler Dr City: Copped ZIP Code: 75019 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 I 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: Coppell 75019 4. Identify the county where the site is located: Dallas 5. Latitude: 32.940079 I Longitude: - 96996199 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) New ??? construction project. 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. I Street Name: City: I State: I 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, Regon 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): Primary: 1542 Secondary: TCEQ -20022 (03/05/2008) Page 2 Owner's NOI pg 3 3(a) What is the total number of acres disturbed? 6 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 4(a) What is the name of the water body(s) to receive the storm water runoff or potential runoff from the site? North Lake 4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventually reach? 0822 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 El No If Yes, provide the name of the impaired water body(s). 4(d) Is the discharge into an MS4? 13 Yes ❑ No If Yes, what is the name of the MS4 Operator? City of Coppell 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 "Yes" to the certifications below. Failure to certify to all items Neill 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. K4 Yes I understand that a Notice of Termination (NOT) must be submitted when this authorization is no longer needed. W 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: 1� • Typed or printed name //required .t nirr he le'ih!e) Title (Required X /e,;ihlr') 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 persona 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. further certify that I am authorized under lit 1 _ \.`y kit Oil ni.7r:lti t t ct._ � nti..a. f to sign and submit this document, and can provide documentation in proof of such authorization upon req est. M Signature: -- Date: 1 0 11-1. lO\ (Use blue ink) 1 (btl 1W21 3/(bT 8) \ Page 3 l. upy 01 - 1 exas 1.U1111111SJ1U11 Ull £11V11U11111C11141 yUAllly - w ww.lt+Gli.JtaI. .tn.U3 t aI t vt ✓ Texas Commission on Environmental Quality Construction Notice of Intent Site Information (Regulated Entity) What is the name of the site to be LANVERA authorized? Does the site have a physical address? Yes Physical Address Number and Street 112 WRANGLER DR City COPPELL State TX ZIP 75019 County DALLAS Latitude (N) (##.###tM) 32.940079 Longitude (W) (- ###.#fit##) - 96.996199 Primary SIC Code Secondary SIC Code Primary NAICS Code Secondary NAICS Code Regulated Entity Site Information What is the Regulated Entity's Number (RN)? What is the name of the Regulated Entity LANVERA (RE)? Does the RE site have a physical address? Yes Physical Address Number and Street 112 WRANGLER DR City COPPELL State TX ZIP 75019 County DALLAS Latitude (N) (##.#ii###) 32.940079 Longitude (VV) (- l##./IMAINt) - 96.996199 What is the primary business of this entity? MCFADDE- Customer (Applicant) Information How is this applicant associated with this Operator site? What is the applicant's Customer Number CN602612566 (CN)? Type of Customer Partnership Full legal name of the applicant: Legal Name MCFADDEN & MILLER LTD https://www9.tceq.state.tx.us/ePermitsExternalWEB/faces/j spPages/CopyOfRecordRepor... 10/20/2011 l.U�y U1 1\GlU1U - 1GACW 1.V1111111JJ1V11 Vii 1,11V11V11111.1/141 '.••4••.> •• •• •••......1. -•-- - - - -- - Texas SOS Filing Number 800002215 Federal Tax ID 751051645 State Franchise Tax ID 17510516457 DUNS Number Number of Employees 101 -250 Independently Owned and Operated? No I certify that the full legal name of the entity Yes applying for this permit has been provided and is legally authorized to do business in Texas. Responsible Authority Contact Organization Name MCFADDEN & MILLER LTD Prefix MR First JON Middle Last JACOBSON Suffix Title VICE - PRESIDENT Responsible Authority Mailing Address Enter new address or copy one from list: Address Type Domestic Mailing Address (include Suite or Bldg. here, PO BOX 59882 if applicable) Routing (such as Mail Code, Dept., or Attn:) City DALLAS State TX ZIP 75229 Phone (#lam -####) 9724012356 Extension Altemate Phone (###- ###-####) 2146970906 Fax (###4###-####) 9724011399 E -mail jon- j ©mcfaddenandmiller.com Application Contact Person TCEQ should contact for questions about this application: Same as another contact? MCFADDEN & MILLER LTD Organization Name MCFADDEN & MILLER LTD Prefix MR First JON Middle Last JACOBSON Suffix Title VICE - PRESIDENT Enter new address or copy one from list: MCFADDEN & MILLER LTD https: / /www9. tceq .state.tx.us /ePermitsExternalWEB /faces /j spPages/CopyOfRecordRepor... 10/20/2011 l.vpy vl lN.GVV1u - lGAQJ L 1J1111111JJIV11 U11 1i11 V 11 UL111V11 al \UAlltJ - vv vv vv. IVVN.JIU.IV. M. UJ 1 Kbv J v ✓ Mailing Address Address Type Domestic Mailing Address (include Suite or Bldg. here, PO BOX 59882 if applicable) Routing (such as Mail Code, Dept., or Attn:) City DALLAS State TX ZIP 75229 Phone (#41#4114,-##114t) 9724012356 Extension Alternate Phone (#11:11-###-##fl#) 2146970906 Fax (#1l#41##41###) 9724011399 E -mail jon- j@mcfaddenandmiller.com CNOI General Characteristics 1) Is the project located on Indian Country No Lands? 2) What is the Primary Standard Industrial 1542 Classification (SIC) Code? 3) If applicable, what is the Secondary SIC Code? 4) Is the project site part of a larger common No plan of development or sale? 5) What is the total number of acres 6 disturbed? 6) What is the name of the water body to NORTH LAKE receive the storm water runoff or potential runoff from the site? 7) What is the segment number(s) of the 0822 classified water body receiving the discharges from the construction site? 8) Is the discharge into an MS4? Yes 8.a. What is the name of the MS4 Operator? CITY OF COPPELL 9) Are any of the surface water bodies No receiving discharges from the construction site on the latest EPA - approved CWA 303 (d) list of impaired waters? 10) Is the discharge or potential discharge No within the Recharge Zone, Contributing zone, or Contributing zone within the Transition zone of the Edwards Aquifer? 11) I certify that a storm water pollution Yes prevention plan has been developed, will be implemented prior to construction, and is compliant with any applicable local sediment and erosion control plans prepared. 12) I certify that I have obtained a copy and Yes understand the terms and conditions of the Construction General Permit (TXR150000). 13) I understand that a Notice of Yes Termination must be submitted when this https://www9.tceq.state.tx.us/ePermitsExternalWEB/faces/j spPages/CopyOfRecordRepor... 10/20/2011 �opy ui IN-V4.1.11 - 1 Val Lll• 11 ValalaV••••• . aJ authorization is no longer needed. Certification I certify that I am authorized under 30 Texas Administrative Code Subchapter 305.44 to sign this document and can provide documentation in proof of such authorization upon request. I 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. 1 am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. 1. 1 am Jon Jacobson, the owner of the STEERS account ER002529. 2. I have the authority to sign this data on behalf of the applicant named above. 3. I have personally examined the foregoing and am familiar with its content and the content of any attachments, and based upon my personal knowledge and /or inquiry of any individual responsible for information contained herein, that this information is true, accurate, and complete. 4. I further certify that I have not violated any term in my TCEQ STEERS participation agreement and that I have no reason to believe that the confidentiality or use of my password has been compromised at any time. 5. I understand that use of my password constitutes an electronic signature legally equivalent to my written signature. 6. I also understand that the attestations of fact contained herein pertain to the implementation, oversight and enforcement of a state and /or federal environmental program and must be true and complete to the best of my knowledge. 7. I am aware that criminal penalties may be imposed for statements or omissions that I know or have reason to believe are untrue or misleading. 8. I am knowingly and intentionally signing Construction Notice of Intent. 9. My signature indicates that I am in agreement with the information on this form, and authorize its submittal to the TCEQ. OPERATOR Signature: Jon Jacobson OPERATOR Account Number: ER002529 Signature IP Address: 163.234.25.197 Signature Date: 2011 -10-20 Signature Hash: 417483Al28CB88A9B25E25D4298A1 C29147B21 EA3270A79D8DDAD99EB1 EC7502 Form Hash Code at D6CO29876C1863A5564A5E02223BF99B079EEDAA543C7856263 time of Signature: Fee Payment Transaction by: The application fee payment transaction was made by ER002529 /Jon Jacobson Paid by: The application fee was paid by JON JACOBSON Fee Amount: 225 Paid Date: The application fee was paid on 2011 -10-20 https: / /www9.tceq .state.tx.us /ePermitsExternalWEB /faces /j spPages /CopyOfRecordRepor... 10/20/2011 l..Vpy VL 1 \G\+V1 — 1liAQJ VV1111111JJaVal vat Lll alviu110,11 ua ' uaaas •• •• •. .wv.i..,«.w...... TransactionNoucher number: The transaction number is 582EA000107994 and the voucher number is 139287 Submission Reference Number: The application reference number is 39422 Submitted by: The application was submitted by ER002529 /Jon Jacobson Submitted Timestamp: The application was submitted on 2011 -10- 20 at 15:25:47 CDT Submitted From: The application was submitted from IP address 163.234.25.197 Confirmation Number: The confirmation number is 48436 Steers Version: The STEERS version is 5.67 Additional Information Application Creator: This account was created by Jon Jacobson https: / /www9.tceq. state. tx .us /ePermitsExternalWEB /faces/j spPages /CopyOfRecordRepor... 10/20/2011