Prologis Park-PT150215Notice of Change (NOC) to an Authorization TCEQ Office Use Only
Permit No.:
for Stormwater Discharges Associated with RN:
Construction Activity under TPDES General CN:
TCECQ Permit (TXR150000)
***** 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1) the permit number is not provided, invalid, or no longer active,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?
TXR15 12993
A. APPLICANT INFORMATION: Search Central Registry at www I 2.tceq.iexaLgayLcrpubL
1. Operator (Permittee)
a. What is the full Legal Name of the current Operator as on the authorization?
Earth Basics Contracting Corp.
b. What is the TCEQ Central Registry Customer Number assigned to this Operator? CN 603969874
2. Permitted Site (required)
What is the TCEQ Central Registry Regulated Entity Number assigned for this permitted site? RN 107726325
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). Go to Section 1 &/or 2 as applicable.
(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 Discharge Monitoring Report forms.
Site Information (Regulated Entity)
(Note: Permits under a general permit are sitespecific. If a change in site location has occurred, this NOC is not attainable.)
X
General Characteristics relating to the regulated activity.
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 chap ed? (check one or more as applicable)
Operator for permit correspondence
Site (RE) Mailing Address and contact information
Billing address/contact for Receiving Annual Fee
Statement
Reporting address/contact for Receiving Discharge Monitoring
Reports (DMRs)
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.
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.: ( )-71
E -Mail:
TCEQ- 20391 (07/13/2007) Page I
3. REGULATED ENTITY (RE) SITE INFORMATION CORRECTION
a. Is this a change to the location of the permitted activity?
Yes - this requested change will not be processed since the authorizations are sitespecific. X No — go to next question.
b. New or Corrected Name of Project or Site
c. Updated Physical Address (new 911 address):
Street Number:
Street Name:
Bldg/Ste No.
City:
ZIP Code:
County (Counties if>1):
d. Update or Corrected location access description, if no physical address (Street Number & Street Name):
e. Corrected Latitude: N
Corrected Longitude: W
4. CHANGE IN CHARACTERISTICS PROVIDED ON ORIGINAL FORM
Identify the specific change and provide the updated information. If an attachment is need, please reference it below.
The number of acres of area disturbed has increased to 108. Scope now involves mass grading for
entire 108ac tract.
C. APPLICATION CONTACT
If TCEQ needs additional information regarding this application, who should be contacted?
1. Name: Brian Colin
Title:
Company: Earth Basics Contracting Corp.
2. Phone No.: 817.349.6322
Fax No.: ( )
E -Mail: brian@earthbasics.net
D. CERTIFICATION
Operator Certification:
4!5d /
1 /r�✓i y+7 A
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 unde' 0 Texas A ministrative Code §305.44 to sign and submit this document, and can provide
documentat' 00 o ch authorizatp t.
Signature: Date: G Z��/ ' 's
(Use blue ink) (REQUIRED) REQUIRED)