EPA Region 4 Sole Source Aquifer Project Review Form - Section A: Project Description

Welcome to the Environmental Protection Agency (EPA) Region 4’s Sole Source Aquifer (SSA) project review form. The EPA SSA Protection Program is authorized by section 1424(e) of the Safe Drinking Water Act of 1974 (42 U.S.C. 201, 300 et. Seq., and 21 U.S.C. 349). Under the SSA Protection Program, EPA reviews proposed projects that will both: 1) be located within the SSA project review area and; 2) receive federal financial assistance. The review area may include the area overlying the SSA, its recharge zone, and source areas of streams that flow into the SSA's recharge zone. The EPA's review is intended to determine any possible contamination to the SSA from submitted projects. Your accurate submission of information will help us determine any possible contamination.

Please complete this form in its entirety and as well as the two-part submission process. Keep the email received at the end of submission process for your records. This email will serve as the official record of the decision and may be required by the federal agency funding your project. Thank you.

Section A: Project Description

Please contact the EPA Region 4 Sole Source Aquifer team at R4_SSA@epa.gov if you encounter problems with this form or have any questions.

Section A: Project Description

Name of Entity *

Please enter the name of the applicant requesting a Sole Source Aquifer (SSA) Review.

Section A: Contact Information

Please provide the following contact information:

Contact Person: *

Contact Email Address *

Contact Mailing Address: *

Address *

Address 2

City/Town *

State/Province *

ZIP Code *

Contact Phone Number *

Please enter the name of the project *

Please enter the project address (physical location - Street, City, State, ZIP) and geographic coordinates, if available. *

Is your project receiving any federal financial assistance, through a grant, contract, loan guarantee, or otherwise? *

Yes

Enter the federal agency and/or authority through which you are receiving the federal financial assistance.

Is the project address completely or partially located within a SSA or a SSA’s recharge zone? *

Use the Interactive map of SSAs to verify. (Please note projects located entirely outside of a SSA area or a SSA’s recharge zone do not require a SSA review by USEPA. The link for the map will open in a new window or tab - depending on your browser.).

Yes

By providing the information above, I certify under penalty of law that this questionnaire was completed under my direction or supervision and the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for known violations.

EPA Region 4 Sole Source Aquifer Project Review Form - Section A: Project Description

Section A: Project Description

Sole Source Aquifers for Drinking Water