Alexander Ct-PT070815
DkI you know YM eaD pay OD 1iDe? Go to https:J/www6.tceq.state.tx.ullepay/
Select Fee Type: OHNERAL PERMIT CONSTRUcnON STORM WATER DISCHARGE NOI APPUCATlON
AppIic8tiH Fee: You must pay the $100 Application Fee to TCEQ for the application to be considered complete.
How did this fee?
Mailed: II ~ 11l."~ QIIIIr Ntr.:
EPAY: Voucher No.:
IMPORTANT:
-Use the attacbed INSTRUcnONS when complctiDg 1his form.
-After completing this form, UlIe the attacbed CUSTOMER CBECKLI8T to make certain all items are complete and accurate.
.., or iDaccmate items ma dela final acknow t or co UIIder the 'L
A. OnttATOR (lIJIIItIcaIIt)
1. If the applicant is currently a c:ustomel' with TCEQ. what is the QJStomer Number (eN) issued to this entity"l CN
2. Wbat is the full Lepl Name of tile applicant?
M/rCJ MOlr Oey, Cti>rp,
(TIle legolname mllSt be 8J1elled exocdy Q8 filed with tlte T_ Secretary of SIaJe. Cowtty. or ill tlte l.,u documenJ.fomrbIg the tmlity.)
3. What is the appJic8nt's mailing address as m:ognized by the US hDI Senke?
Address: Suite No./BldS. NoJMail Code:
ZIP Code:
Postal Code:
"
II
fOr " Ldrr!:! Dd v/S
Notice of Intent (NOI) for Storm Water
Discharges Associated with Construction
Activity under TPDES General Permit
(TXR150000)
TCEQ 0IIice Use 0DIy
Permit No.:
RN;
CN:
Sip up ROW for on IDe NOI at bttp:llwww.tceq.state.tx.uslpermittioglsteenlsteen.btml Get IDstut Approval
Name Printed on Check:~i- 01
Is the Payment Voucher copy attached?
Country Code:
Extension:
E-maiJAddress:John.)lawl<in5@-f)(.r. , cOd)
DSole Proprietorship-D.B.A.
OFedera1 Government
[]county Government
D Limited Partnership
DGeneral Partnership
Deity Government
TX sas Charter (filing) Number:
B. BILLING ADDRESS
The Operator is fClIPODSible for paying the annual fee. The annual fee wiD be useI8ed to permits aetiYe .. SepteBIber 1 of ellClI yeu'. TCBQ will send a
bill to the address . ded in this section. The is ible for termiDatin the 't when it is DO I needed.
Is the billing address same as the 0peIat0r Address? Yes, go to SeetioD c. No. fill out SectiH B
1. Billing Mailing Address:
City: State:
2. Country Mailing Information (if outside USA). Territory:
3. BilliDg CoDtact (Atbl or C/O):
4. Phone No.: ( )
5. Fax No.: ( )
Suite No.IBldg. No./Mail Code:
ZIP Code:
Country Code: Postal Code:
Extension:
E-mail Address:
TCEQ-20022 (12/0 112006)
Page 1
C. APPUCATION CONTACf
IfTCEQ needs additioDaI infotmatioll regarding this application, who should be contacted?
1. Name: rim Title:
2. Phone No.: (!!J7 )
3. FaxNo.: ~'7 .. 3 E-mail Address: rimhen. '.3@veri~Dn . net-
D. REGULATED ENTITY (RE) INFORMATION ON PROJECT OR SITE
1. TCEQ Issued RE Reference Number (RN) (if available):
2. Name of Project or Site (the IIlIJDe as known by the community where this ficilitylprojcct is locawd):
J9lexander Courf.Subdlvislon
(example: phase aDd name of subdivision or name of project that's unique to the site)
3. Physical Address ofProjcct or S~: (enter in spaces below)
Street Nwnber: Street Name:
City: ZIP Code: County (Counties if> I):
4. If no pbysicel address (Street Number & Street Name), JWVide a written location aa:ess description to the site:
(Ex.: pbasc I of Woodland subdivision locatIcd 2 miles west ftom in~~ ofH 290 & IH3S accessible on Hwy 290 South)
M,4 I<d,d. en"D d
s. Latitude: !J "-5' N Longitude: ~'7"- 00' W
6. What is the ~ business orthis entity? In your own words, briefly descnbe the primary business oftbc Regulated Entity:
(DoDQtrepcattheSICandNAlCScodc) 0. I ~ J...J. D I t
I,e~ ~-Si~,e eV~/(1)f>men
7. What is the mailiDg addn:ss 8Dd contact infonDation for the n:gu1atcd entity?
Is the RE mailing address the same as the Operator? 1SYcs, address is the same as Operator DNa. provide the address
Street Number: Street Name:
City: State: ZIP Code:
E. GENERAL CBARACTERISTICS
I. I certifY that the projcc:tlsite is BOt located on Indian Country Lands? Yes No
If No OIl must obtain autborization EPA,' n VI.
2. Is this NOI bciDg submitted due to a cbaDgc in Operator? Yes No
3. What is the S1aDd8rd 1Ddustri81 Classification (SIC) code (see iDstructions tor COIIIJI1OD codes):
Primary: I t$ / / SccoDdary: / tP Z 3
4. What is the total Dumber of acres disturbed? :1= .
Is the project site pert of a larger common plan of development or sale? oY es I8JNo
If VII, the totalllUlDber ofacrcs disturbed can be less than S acres.
If No, the total Dwnber of acres disturbed must be S or more. If the total number of acres disturbed is less thaD 5 tbcD the project site docs not qualify for
coverage tbrougb this Notice oflDtCDt. Coverage will be denied. See the nlq1IitemcDts in the general permit for small construction sites.
S. Discbar8c Information
a What is the name orthe first wala'body to receive the storm water runoff or potential runoff from the site?
b. What is the segment DlUDbeJ(S) ofthc classified water bod:y(s) tbat the discbarge or potential discbargc will evcntuaDy TeaCh?
c. Is the discharge into aD MS4? Yes No
If Va, wblIt is the name ofthc MS4 Operator?
Note: The general permit requires you to send a copy ofthc NOI to the MS4 Operator.
6. Is the discharge or potential discharge within the Recharge Zone, Contributing Zone. or Contributing Zone within the Transition Zone
of the Edwards Aquifet? Dyes f8'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 in the Storm Water Pollution Prevention Plan.
TCEQ-20022 (12/0 1/2006)
Page 2
F. CEll'ImCATION
ChecIc "Y cs- to the certifications below. Fahre to indicate ayes" to ALL iteIDI may result in denial of coverage under the general permit.
I certify that I have obtained a copy and undeJstand the terms and conditions of the general permit TXlSOOOO.
I certify that the activities at this site qualify for coverage under the general permit TXI soooo.
I understand that a Notice of Termination (NOT) must be submitted when this authorization is no longer needed.
I understand that permits active on September 1 st of each year will be assessed an Annual Water Quality Fee.
I certify that a Storm Water Pollution Prevention Plan (SWP3) has been prepared and implemented as requiIed by the geneIal permit
~Yes
tiayes
IS Yes
tKI Yes
rsYes
Opentor CerlIfIadoB:
1, Mtra Mar D6IY, Co~'
Typed or printed name inti)
Jt!1hn I. I lIawl</r)-~ fi-es.
Title (RetJIIbwI)
certify UDder pcma1ty oflaw that this doc:umcnt and all attacbments were prepared under my dUecti<m or supervision in accordance with a system designed
to assure that qualified pcrsonncI properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the
system, or those persOIlS ctiJectly responsible for ptbering the information, the infounation submitted is, to the belt ofmy knowledge and belief, 1rUe,
accumte, and complete. I am aware there are sigaificant penalties for submitting false informa1ion. including the possibility offine and imprisonment for
knowing violations.
I further certify that I am authorized under 31 Texa. AdmiDiItndve Code S3I5M to sign and submit this document:, and can provide documentation in
proof of such ,
Signature:
Date:
8 -It;' -CJ7
TCEQ-20022 (1210112006)
Page 3
Texas CommissioB OB EBviroBmeBtaI QuaHty
General Permit Payment Submittal Form
Use 1his form to submit your App1ic:ation Fcc only if you an: maiq your payment
-Complete itaDS 1 through 5 below:
_StIplc your check in tbe space proW:lcd at tbe bottom of1his docwncnt.
. Do DOt mail1his form with your NOI fonD.
-Do DOt mail1his form to the same address as your NOI.
Mail this form and oar cheek to:
BY REGULAR U.s. MAIL .
BY OVERNIGIIT/EXPRESS MAIL
Texas ~ on EDYilonmeotal Quality
FinaDcial AdmiDistration Division
Casbier's Office, MC-214
P.O. Box 13088
A . TX 78711-3088
Fcc Code: GPA
1. Check
2. Amount ofCbec:kIM
3. Date of Check or M
4. Name on Check or M
Texas Commission on Environmental Quality
FiDancial.Adm.iDistlatio Division
Casbier's Office, MC-214
12100 Park 35 Circle
. TX 78753
S. NOI INFORMATION
Il/eXdnder Ceurf SLJlJcI/V/~/D/)
ProjectlSitc (RE) PhysiCal Address:
;Y: ~ C~rner (91' B~fhe/ f( eI, c7/Jd
D~nft.9n To>p RcJ~J Ct:Jj>fe/~ Tx,
32-1515-1110
5197
MIRA MAR DEVELOPMENT CORP.
6003 SUNDERlAND DRIVE
COLLEYVILLE, TX 76034
...
.. 8../.5"-LJ'1
TCEQ-20J
I ~. /:c.s.a. l$jOO~'
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III WACHOVIA
Wachovla Bank, N.A.
wachovla.com
..11/(fXO>r>r/er Cev,...-!-
I: ~ ~.O ~ 5 ~ 5111: 20000 ~q 2 1. 2l.l. 111- 5 ~11
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