Notice of Intent - TCEQ e-Services - Texas.gov

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Total Outfalls:How many outfalls are stormwater?How many outfalls are wastewater?How many outfalls are stormwater combined with wastewater?Note: A Discharge Monitoring Report (DMR) is required for outfalls dischargingwastewater and wastewater combined with stormwater.ii. What is the name of the first water body to receive the discharge?iii. What is the segment number(s) of the classified water body(s) that the discharge willeventually reach?iv. Provide a complete description of the discharge route from each outfall to the nearestclassified segment:v. Is the discharge into Marine Water or Fresh Water? (This information will be used todetermine applicable monitoring requirements specified in the general permit.)Select one:Marine WaterFresh Watere) Edwards Aquifer Rule:Is the discharge or potential discharge within the Recharge Zone, Contributing Zone, withinthe Contributing Zone within the Transition Zone, or zero to ten (0 to 10) miles upstream ofthe Recharge Zone of the Edwards Aquifer? Yes NoIf the answer is Yes, please note that a site specific authorization approved by the ExecutiveDirector under the Edwards Aquifer Protection Program (30 TAC Chapter 213) is required. Acopy of the agency approved Contributing Zone Plan or Water Pollution Abatement Planshould be included as part of the Stormater Pollution Prevention Plan.f) Contact Responsible for Discharge Monitoring Reports (EPA 3320-1) :Provide the name of the person and their complete mailing address delegated to receive andsubmit Discharge Monitoring Report Forms.Prefix (Mr. Ms. Miss):First/Last Name:Suffix:Title:Credential:Phone No.: Ext: Fax No.:E-mail:Mailing Address:Internal Routing (Mail Code, Etc.):City: State: ZIP Code:If outside USA: Territory: Country Code: Postal Code:Did you know you can submit DMR data online?Sign up now at: http://www.texasnetdmr.orgEstablish an electronic reporting account when you get your permit number.TCEQ 10319 (11/07/2011) Page 6
7) CERTIFICATIONCheck Yes to the certifications below. Failure to indicate Yes to ALL items may result in denial ofcoverage under the general permit.a) I certify that I have obtained a copy and understand the terms and conditions of the generalpermit TXG110000.Yesb) I certify that the activities at this site qualify for coverage under the general permitTXG110000.Yesc) I understand that a Notice of Termination (NOT) must be submitted when this authorizationis no longer needed.Yesd) I understand that permits active on September 1st of each year will be assessed an AnnualWater Quality Fee.Yese) I certify that the full legal name of the entity applying for this permit has been provided and islegally authorized to do business in Texas.YesTCEQ 10319 (11/07/2011) Page 7
Page 1 and 2: TCEQ Office Use OnlyPermit No.:RN:C
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Page 9 and 10: CUSTOMER GP NOTICE OF INTENT CHECKL
Page 11 and 12: Change in Operator or OwnerAn autho
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Page 15 and 16: Corporations and Limited Partnershi
Page 17 and 18: describing mitigation measures, the
Page 19 and 20: (3) For a municipality, state, fede

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