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Pre-Application Form
Pre-Application Form
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EPA - REGION II INDIAN NATION DRINKING WATER INFRASTRUCTURE GRANT PRE-APPLICATION FORM
Indian Nation:_________________________Date:_______________ |
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Instructions - Complete the pre-application form and submit it to: US Environmental Protection Agency Region II
A. Type of Project - Please fill out a separate pre-application form for each type of project. Please Check one only.
Source _____ New ground water source _____ New surface water source _____ Rehabilitation of a ground water source _____ Rehabilitation of a surface water source
Treatment _____ New treatment _____ Rehabilitation of treatment
Storage _____ New storage _____ Rehabilitation of storage
Transmission and/or Distribution System Lines _____ New (incorporation of areas not served by a public water system (PWS) - must be subject to contamination) _____ New (consolidation of water systems or interconnection with another water system) _____ Rehabilitation of transmission and/or distribution system lines
New PWS _____ Source, treatment, storage, transmission and/or distribution system lines B. System Information - Existing PWS information only. Please list any proposed system information in the Project Description section. Name of Public Water System (PWS): __________________________________________________ (PWS) Identification Number: __________________________________________________ System Address (Include County): __________________________________________________ __________________________________________________ __________________________________________________ Owner of PWS: __________________________________________________ __________________________________________________ __________________________________________________ Owners Address: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ PWS Operator: ________________________________________________ (If the operator is currently licensed, please note here along with the type of license). Population served by the PWS: __________________________________________________ Number of PWS Service Connections: __________________________________________________ Indian Nation Median Household Income: __________________________________________________ (Identify the source of information)
C. Project Cost Estimate - Please provide a project cost estimate for the following: Allowance for Planning & Design (see allowance table in Intend Used Plan) $___________ Construction $___________ Construction Contingencies (10% maximum) $___________
Construction Related Engineering Services $___________ Administrative Service $___________ Total $___________ Identify the source of information for the cost estimates: __________________________________________________ __________________________________________________ D. Project Description - Attach a brief description of the project. Include reasons and need for the project. Describe the problem the project will correct. List any current and/or past exceedance of drinking water standards (within the past 5 years). Projects will be ranked for funding based on pre-applications. Contact: Poon.Robert@epa.gov |
