Fresenius-PT130717 TCEQ Office Use Only
Permit No.:
RN`.
Region:
simismon
PP" 4 ; 5
Pot" 6
TCEQ Notice of Intent (NOI) for Stormwater Discharges
Associated with Construction Activity under TPDES
General Permit (TXRl50000)
IMPORTANT: •
• Use the INSTRUCTIONS to fill out each question in this form.
• Use the CHECKLIST to make certain all you filled out all required information.
Incomplete applications WILL delay approval or result in automatic denial.
.• Once processed your permit can be viewed at: •
http://www2.tceq.texas.gov/wq dpa/index.efrn
ePERMITS: Sign up now for online NOI: https://www3.tceq.texas.gov/steers/index.cfan
Pay a $225 reduced application fee by using ePermits.
APPLICATION FEE:
• You must pay the$325 Application Fee to TCEQ for the paper application to be
completc.
• Payment and NOI must be mailed to separate addresses.
• Did you know you can pay on line?
• Go to https://www3.tceq.texas.govf epay/index,cfm •
• SE.lect Fee Type: GENERAL PERMIT CONSTRUCTION STORM WATER
DJISCHARGE NOI APPLICATION
• Provide your payment information belo r verification •" : ent:
[]Mailed Check/Money Order ■ o.:
Name Printed on Ch.ck: AV Cal Properties, LLC
[]EPAY Voucher No.:
Is the Payment Voucher : attac• ••' ■ Yes
RENEWAL: Is this NOI a Renewal of an existing General Permit Authorization?
(Note:A pe rmit cannot be renewed after June 3, 2013.)
[]Yes The Permit number is:TXR15
(If a permit number is not provided,a new number will be assigned.)
[]No •
1) OPERA OR(Applicant)
a) If the applicant is currently a customer with TCEQ,what is the Customer Number(CN)
issued to this entity? You may search for your CN at:
http://wviwi 2.tceq.texas.gov/crpub/index.elm?fuseaction=cust.CustSearch
CN
TCEQ 20022(03/05/2013) Page 1
b) What is the Legal Name of the entity(applicant)applying for this permit?
AV Cal Properties,LLC
(The legal name must be spelled exactly as filed with the Texas Secretary of State,County,or
in the legal document forming the entity.)
c) What is the name and title of the person signing the application? The person must be an
executive official meeting signatory requirements in TAC 305.44(a).
Prefix(Mr.Ms.Miss):
First/Last Name: Ed Harmon Suffix: _
Title: Managing Partner Credential:
•
d) What is the Operator Contact's(Responsible Authority)contact information and mailing
address as recognized by the US Postal Service(USPS)? You may verify the address at: •
http://zip4.usps.com/zips./welcome jsp
Phone#:(410,697-0275 ext: Fax#:
E-mail:
Mailing Address:4209 Corduroy Rd
Internal Routing(Mail Code,Etc.):
City: Oregon State:Ohio ZIP Code: 43616
If outside USA: Territory: Country Code: Postal Code:
e) Indicate the type of Customer(The instructions will help determine your customer type):
❑Individual ❑Limited Partnership ❑Sole Proprietors hip-DBA
❑Joint Venture ❑ General Partnership 0 Corporation
❑Trust ❑Estate ❑Federal Government
❑State Government ❑County Government ❑City Government
❑Other Government
f) Independent Operator? p Yes ❑No
(If governmental entity,subsidiary,or part of a larger corporation,check"No".)
g) Number of Employees:
D o-2o; 021-loo; 0101-25o; ❑251-50o; or ❑501 or higher
•
h) Customer Business Tax and Filing Numbers:
(REQUIRED for Corporations and Limited Partnerships. Not Required for Individuals,
Government,or Sole Proprietors)
:State Franchise Tax ID Number: 32050430654
Federal Tax ID: 510558877
Texas Secretary of State Charter(filing)Number: 8o1749133
DONS Number(if known):
2) APPLICATION CONTACT
If TCEQ needs additional information regarding this application,who should be contacted?
Is the application contact the same as the applicant identified above?
0 Yes,go to Section 3). ❑ No,complete section below.
Prefix(Mr.Ms.Miss):
First/Last Name: Suffix:
Title: Credential:
TCEQ 20022(03/05/2013) Page 2
Organization Name:
Phone No.:_ ext: Fax Number:
E-mail:
•
Mailing Address:.
Internal Routing(Mail Code,Etc.):
City: State: ZIP Code:
Mailing Information if outside USA:
Territory: Country Code: Postal Code:
.TED ENTITY(RE) INFORMATION ON PROJECT OR SITE
If the site'of your business is part of a larger business site or if other businesses were located at
this site before yours,a Regulated Entity Number(RN)may already be assigned for the larger
site. Use the RN assigned for the larger site. Search TCEQ's Central Registry to see if the larger •
•
site may already be registered as a regulated site at:
http://wwwl 2.lceq.texas.gov/crpub/i ndex.cfm?fuseaction=regent.RNSearch,
If the site is found,provide the assigned Regulated Entity Reference Number and provide the
information for the site to be authorized through this application below. The site information
for this authcrization may vary from the larger site information.
a) TCEQ issaed RE Reference Number(RN): RN
•
b) Name of project or site(the name known by the community where located):
TruBlu Logistics
c) In your o■vn words,briefly describe the primary business of the Regulated Entity: (Do not
repeat the SIC and NAICS code):
Construction of warehouse
d) County(cr counties if> 1) Dallas
e) Latitude: 32.9544 Longitude: -97.0244
f) Does the site have a physical address?
❑Yes,complete Section A for a physical address.
QNo,complete Section B for site location information.
Section A: Enter the physical address for the site.
Verify the address with USPS.If the address is not recognized as a delivery address,provide
the address as identified for overnight mail delivery,911 emergency or other online map.
tools to confirm an address.
Physical Address of Project or Site:
Street Number: 371 Street Name: Royal Ln.
City: DEW Airport Stale: Texas ZIP Code: 75261
TCEQ 20022(03/05/2013) Page 3
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.: located 2 miles west from intersection of Hwy 290 IH35
accessible on Hwy 290 South)
City where the site is located or,if not in a city,what is the nearest city:
State: Texas ZIP Code where the site is located:
4) GENERAL.CHARACTERISTICS
a) Is the project/site located on Indian Country Lands?
❑Yes-If the answer is Yes,you must obtain authorization through EPA,Region 6.
D No
b) Is your construction activity associated with a facility that,when completed,would be
associated with the exploration,development,or production of oil or gas or geothermal
resources?
❑•Yes-If the answer is Yes,you may be under jurisdiction of the Railroad Commission
of Texas and may need to obtain authorization through EPA, Region 6.
D No
e) What is the Primary Standard Industrial Classification(SIC) Code that best describes the
construction activity being conducted at the site?
Primary SIC Code: 1542
d)'If applicable,what is the Secondary SIC Code(s):
e) What is the total number of acres disturbed? 29
Is the project site part of a larger common plan of development or sale?
❑Yes-If the answer is Yes,the total number of acres disturbed can be less than 5 acres.
p No -If the answer is 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.
g) What is the name of the first water body(s)to receive the stormwater runoff or potential
runoff from the site?
unnamed tributary of Grapevine Creek
h) What is the segment number(s)of the classified water body(s)that the discharge will
.eventually reach?
o822B
TCEQ 20022(03/05/2013) Page 4
•
i) Is the discharge into an MS4?
D Yes-If the answer is Yes,provide the name of the MS4 operator below.
❑ No
If''es,provide the name of the MS4 operator:
DIW Airport and City of Coppell
Note: The general permit requires you to send a copy of the NOI to the MS4 operator.
j) 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-If the answer is Yes,provide the name(s)of the impaired water body(s)below.
D No
If Yes,provide the name(s)of the impaired water body(s):
k) Is the discharge or potential discharge within the Recharge Zone,Contributing Zone,or
Contributing Zone within the Transition Zone of the Edwards Aquifer as defined in 3o TAC
Chapter"213?
❑ Yes-If the answer is Yes,complete certification below by checking"Yes."
CI No
I certify that a copy of the TCEQ approved Plan required by the Edwards Aquifer Rule
(3o TAC Chapter 213)is either included or referenced in the Stormwater Pollution
Prevention Plan.
t] Yes
TCEQ 20022(03/05/2013) Page 5
5) CERTIFICATION
Check Yes to the certifications below. Failure to indicate Yes to ALL items may result in denial
of coverage under the general permit.
a) I certify that Ilrave obtained a copy and understand the terms and condition:;of the
Construction General Permit(TXR150000). D Yes •
b) I certify that the full legal name of the entity applying for this permit has been provided
and is legally authorized to do business in Texas. D Yes
c) I understand that a Notice of Termination(NOT)must be submitted when this
authorization is no longer needed. D Yes
d) I certify that a Stormwater Pollution Prevention Plan has been developed,will be
implemented prior to construction and to the best of my knowledge and belief is
compliant with any applicable local sediment and erosion control plans,as required in
the general permit TXR150000. Note: For multiple operators who prepare z shared
SWP3,the confirmation of an operator may be limited to its obligations under the
SWP3 provided all obligations are confirmed by at least one operator. 0 Yes
:Operator Certification:
I, Ed Harmon Managing Part aer
Typed or printed name Title
•
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: /f 3
(Use blue ink) l
TCEQ 20022(03/05/2013) Page 6