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TCEQ
LARGE CONSTRUCTION SITE NOTICE
FOR THE
Texas Commission on Environmental Quality (TCEQ)
Storm Water Program
TPDES GENERAL PERMIT TXR150000
"PRIMARY OPERATOR"NOTICE
This notice applies to construction sites operating under Part II.E.3.of the TPDES General Permit Number
TXR150000 for discharges of storm water runoff from construction sites equal to or greater than five acres,
including the larger common plan of development. The information on this notice is required in Part III.D.2.
of the general permit. Additional information regarding the TCEQ storm water permit program may be
found on the internet at:
http://www.tceq.state.tx.us/nav/permits/wq construction.html
Site-Specific TPDES Authorization Number: TXR 15 14 I
Operator Name: The Ridgemont Company
Shawn Thomas/Project Manager
Contact Name and Phone Number: (469) 816-3384
LA Fitness Coppell
Project Description: Physical address or description of North side of SH 121, 600 feet west of N. Denton Tap
the site's location, and estimated start date and projected Road in Coppell, TX 75019
end date, or date that disturbed soils will be stabilized. Estimated Start Date: January 2018
Projected End Date: May 2019
Location of Storm Water Pollution Prevention Plan: Job site trailer or call above number.
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Copy of Record Page 1 of 6
Texas Commission on Environmental Quality
Construction Notice of Intent
Site Information (Regulated Entity)
What is the name of the site to be authorized? LA Fitness Coppell
Does the site have a physical address? No
Because there is no physical address, North side of SH 121, 600 feet west of N.
describe how to locate this site: Denton Tap Road
City Coppell
State
TX
ZIP 75019
County DALLAS
Latitude(N)(##.######) 32.9886
Longitude(W)(-###.######) -96.9954
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 LA Fitness Coppell
(RE)?
Does the RE site have a physical address? No
Because there is no physical address, North side of SH 121, 600 feet west of N.
describe how to locate this site: Denton Tap Road
City
Coppell
State
TX
ZIP
75019
County DALLAS
Latitude(N)(##.######) 32.9886
Longitude(W)(-4441.######) -96.9954
What is the primary business of this entity?
Customer (Applicant) Information
How is this applicant associated with this site? Operator
What is the applicant's Customer Number CN602551509
(CN)?
https://www 19.tceq.texas.gov/epermitsExternal/faces/views/reports/copyOfRecordReport.... 1/1 6/20 1 8
Copy of Record Page 2 of 6
Type of Customer Corporation
Full legal name of the applicant:
Legal Name The Ridgemont Company
Texas SOS Filing Number 38446300
Federal Tax ID 751515482
State Franchise Tax ID 17515154825
DUNS Number
Number of Employees 21-100
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 The Ridgemont Company
Prefix
First Jason
Middle
Last Lillard
Suffix
Title President
Responsible Authority Mailing Address
Enter new address or copy one from list:
Address Type Domestic
Mailing Address(include Suite or Bldg. here, if 1520 W WALNUT HILL LN
applicable)
Routing (such as Mail Code, Dept.,or Attn:)
City IRVING
State TX
ZIP 75038
Phone(###-###-####) 4698163384
Extension
Alternate Phone(###-###-####)
Fax(##########)
E-mail
Application Contact
Person TCEQ should contact for questions
about this application:
https://www 19.tceq.texas.gov/ePermitsExternal/faces/views/reports/copyOfRecordReport.... 1/16/2018
Copy of Record Page 3 of 6
Same as another contact?
Organization Name EnviroServe
Prefix
First Jeremy
Middle
Last Boucher
Suffix
Title Consultant
Enter new address or copy one from list:
Mailing Address
Address Type Domestic
Mailing Address(include Suite or Bldg. here, if 126 W CHURCH ST
applicable)
Routing(such as Mail Code, Dept., or Attn:)
City LEWISVILLE
State
TX
ZIP 75057
Phone(#1##-###-####) 2149073981
Extension
Alternate Phone(###-###-####)
Fax(######-tt#tt#itt#it)
E-mail jboucher@enviroserve.co
CNOI General Characteristics
1) Is the project located on Indian Country No
Lands?
2)Is your construction activity associated with No
a facility that,when completed, would be
associated with the exploration,development,
or production of oil or gas or geothermal
resources?
3)What is the Primary Standard Industrial 1542
Classification (SIC)Code that best describes
the construction activity being conducted at the
site?
4)If applicable,what is the Secondary SIC
Code(s)?
5) Is the project site part of a larger common Yes
plan of development or sale?
6)What is the total number of acres disturbed? 7
https://www 19.tceq.texas.gov/ePermitsExternal/faces/views/reports/copyOfRecordReport.... 1/1 6/20 1 8
Copy of Record Page 4 of 6
7)What is the name of the first water body(s) Denton Creek
to receive the stormwater runoff or potential
runoff from the site?
8)What is the segment number(s)of the 0825
classified water body(s)that the discharge will
eventually reach?
9)Is the discharge into an MS4? Yes
9.1.What is the name of the MS4 Operator? City of Coppell
10)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?
11)Is the discharge or potential discharge No
within the Recharge Zone, Contributing zone,
or Contributing zone within the Transition zone
of the Edwards Aquifer,as defined in 30 TAC
Chapter 213?
12)I certify that a stormwater pollution Yes
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
operate under a 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.
13)I certify that I have obtained a copy and Yes
understand the terms and conditions of the
Construction General Permit(TXR150000).
14)I understand that a Notice of Termination Yes
(NOT)must be submitted when this
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. I am aware there are significant penalties for submitting false information, including the
possibility of fine and imprisonment for knowing violations.
https://www 19.tceq.texas.gov/ePermitsExternal/faces/views/reports/copyO fRecordReport.... 1/16/2018
Copy of Record Page 5 of 6
1. I am Jason Lillard, the owner of the STEERS account ER013381.
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:Jason Lillard OPERATOR
Account Number: ER013381
Signature IP Address: 97.77.59.42
Signature Date: 2018-01-16
Signature Hash: DF3074C4E87BD80F7669FC422718707443313C751372E630CB1E96C4FB15E1A2
Form Hash Code at time of 816074F2759C489DC514A8CBF60DCA8A6B9A195A9A4EFB4C27812E86C1192014
Signature:
Fee Payment
Transaction by: The application fee payment transaction was
made by ER013381/Jason Lillard
Paid by: The application fee was paid by JASON
LILLARD
Fee Amount: $225.00
Paid Date: The application fee was paid on 2018-01-16
TransactionNoucher number: The transaction number is 582EA000283098
and the voucher number is 348839
Fee Payment
Transaction by: The application fee payment transaction was
made by ER013381/Jason Lillard
Paid by: The application fee was paid by JASON
LILLARD
https://www 19.tceq.texas.gov/ePermitsExternal/faces/views/reports/copyOfRecordReport.... 1/16/2018
Copy of Record Page 6 of 6
Fee Amount: $225.00
Paid Date: The application fee was paid on 2018-01-16
TransactionNoucher number: The transaction number is 582EA000283098
and the voucher number is 348839
Submission
Reference Number: The application reference number is 201568
Submitted by: The application was submitted by
ER013381/Jason Lillard
Submitted Timestamp: The application was submitted on 2018-01-16
at 11:22:44 CST
Submitted From: The application was submitted from IP address
97.77.59.42
Confirmation Number: The confirmation number is 179361
Steers Version: The STEERS version is 6.15
Additional Information
Application Creator:This account was created by Jeremy M Boucher
https://www 19.tceq.texas.gov/ePermitsExternal/faces/views/reports/copyOfRecordReport.... 1/16/2018