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TCEQ Office Use Only
Notice of Intent (NOI) for Storm Water Permit No.: TXR15
Discharges Associated with Construction RN:
droguul Activity under TPDES General Permit CN:
TCEQ (TXR150000) Ref No:
Sign up now for ePermits NOI at www6.tceq.state.tx.us /steers
Get Instant Permit Coverage and only pay a S225 application fee.
o �oss • ° °' If filing a paper NOI you can pay the application fee on line? Go to www.tceq.state.tx.us /epav
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?
rIYes - What is your permit number? Permit No. TXR15�
El No - a permit number will be issued.
Application Fee if mailing a paper NOI:
You must pay the S325 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.: 8308 Company Name on checking account: Brock Environmental Services, LLC.
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 601460397 (Search Central Registry)
2. What is the Legal Name of the entity (applicant) applying for this permit?
JRJ Paving, L.P.
(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: Marty Murphy Job Title: Bus iness Manager
4. What is the Operator's (applicant) mailing address as recognized by the US Postal Service? (verify at USPS.com)
Address: 1805 Royal Lane Suite No./Bldg. No. /Mail Code:
City: Dallas State:Texas ZIP Code: 75229
Country Mailing Information (if outside USA). Country Code: Postal Code:
5. Phone No.: (214 ) 466 -8640 Extension:
6. Fax No.: (214 ) 466 -8352 E -mail Address: martym@jrjpaving.com
7. Indicate the type of Customer:
D Individual DSole Proprietorship- D.B.A. ® Limited Partnership
D Corporation ❑Federal Government 0General Partnership
0 State Government County Government Cit Government
Other Government ❑ Other (describe):
TCEQ -20022 (03/05/2008) Page 1
8. Independent Operator: ® Yes QNo (If governmental entity, subsidiary, or part of a larger corporation, check "No ".)
9. Number of Employees: 00-20; 021 -100; U101-250; 0251 -500; or 0501 or higher
O. 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 12/463 -5555 )
State Franchise Tax ID Number: 17519406230 Federal Tax ID: 751940623
TX SOS Charter (filing) Number: 800031396 DUNS Number (if known):
B. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: Keith Marvin Title: Project Engineer Company: JRJ Paving, L.P.
2. Phone No.: ( 214 ) 466 -8340 Extension:
3. Fax No.: E -mail Address:
214 466 -8352 kmarvin @jrjpaving.com
C. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SI"I'E
1. TCEQ Issued RE Reference Number (RN): RN
(Search Central Reeistrv)
2. Name of Project or Site (the name as known by the community where this facility /project is located):
Old Town Coppell and Bethel Rd Infrastructure Improvements
(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 $14:tritW for a physical address.
If No, complete gii:Wia for site location information.
Sc164 Enter the physical address for the site. (verify it with USPS.com or other delivery source)
Street Number: Street Name:
City: ZIP Code:
113 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)
Northwest Corner of South Coppell Road and Burns Street
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 County
5. Latitude: 32 57' 7.89" Longitude: 97 0' 22.02"
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) Road Improvements
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 [j No, provide the address
Street Number: Street Name:
City: State: ZIP Code:
D. GENERAL CHARACTERISTICS
1. Is the site located on Indian Country Lands? 11 No DYes — 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: 1611 Secondary: 1623
TCEQ -20022 (03/05/2008) Page 2
3(a) What is the total number of acres disturbed? 25.8
3(b) Is the project site part of a larger common plan of development or sale? ['Yes 1St No
.1 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 MU T, be provided or thepermit 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?
Grapevine Creek
4(b) What is the segment number(s) of the classified water body(s) that the discharge or potential discharge will eventually
reach? 0822B
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 Q No
If Yes, provide the name of the impaired water body(s). Grapevine Creek
4(d) Is the discharge into an MS4? 112 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?
0 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
included or referenced in the Storm Water Pollution Prevention Plan.
E. CERTIFICATION
Check "Yes" to the certifications below. Failure to certify to all items will result in denial.
in 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.
IN 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:
Marty Murphy Business Manaaer
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 evaluaythe information submitted. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gatheringie information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware there are significant'enalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations. ,/
I further certify that I am authorized under 3 Texas/Administrative Code 005.44 to sign and submit this document, and can provide documentation in
proof of such authorization upon reque t, /
ignature: Date: ) D / /l 1
(Use blue ink)
TCEQ -20022 (03/05/2008) Page 3