APPLICANT INFORMATION
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1 APPLICANT INFORMATION Oregon Department of Environmental Quality Clean Water State Revolving Fund Program Point Source Project Application (Design or Construction Projects) 1. Public Agency/Legal Applicant Name Address City, State Zip + 4 Congressional District(s) Telephone Fax Address DUNS Number (9 Digits) 2. Project Contact Name Telephone Fax Address 3. Water Quality Permit Information NPDES permit number: (EPA reference number beginning with "OR") WPCF permit number: 4. CWSRF Loan Request: $ 5. Total Estimated Project Cost: $ 10-WQ-008 Last Updated: 1/16/2015 1
2 PROJECT DESCRIPTION 6. Project Type: (check one or both, as appropriate) Design Construction 7. Project Description Describe proposed project in detail; include the major components of project; any water quality or public health issue addressed by proposed project; how proposed project will address these issues; intended outcome of this project and any other pertinent information that explains why this project is proposed. If there are other anticipated sources of funding for this total project, please indicate those amounts and their funding sources in #34, Table B. Attach a copy of the source of this estimate (as Attachment A) and note the date the estimate was prepared. 10-WQ-008 Last Updated: 1/16/2015 2
3 8. Project addresses a water quality improvement or restoration need for a small community? If, yes provide current population 9. Project includes Sponsorship Option? Yes** No **If yes, applicant must complete and submit a Sponsorship Option application with this application. Application located at: under Sponsorship Option. 10. Project Categories Estimate the percentage of the proposed CWSRF loan expected to be used for each of the appropriate categories shown below. Project Category I II III-A III-B IV-A IV-B V VI VII X Description Secondary Treatment Plant (includes but not limited to new, expansion, or improvements; effluent disposal; biosolids treatment, biosolids disposal, water reuse Advanced Treatment Infiltration/Inflow Correction (I/I) Sewer System Replacement/Rehabilitation New Collector Sewers and Appurtenances New Interceptor Sewers and Appurtenances Combined Sewer Overflow (CSO) Correction Storm Sewers Nonpoint Source Water Resource Activity Recycled Water Distribution % CWSRF Funding Total 100 % 11. Project Location (if different from public agency location) Address City, State Zip + 4 Congressional District(s) Latitude Longitude 10-WQ-008 Last Updated: 1/16/2015 3
4 GREEN PROJECT Refer to Green Project Reserve Project Eligibility Guidance to complete the following questions Does project incorporate or expand green stormwater infrastructure? If yes, describe. Business case required? Yes* No Estimated cost of the green stormwater infrastructure portion of requested loan: 13. Does project incorporate or expand water efficiency? If yes, describe. Business case required? Yes* No Estimated cost of the water efficiency improvement portion of requested loan: *If yes, submit business case with application. 10-WQ-008 Last Updated: 1/16/2015 4
5 14. Does project incorporate or expand energy efficiency? If yes, describe. Business case required? Yes* No Estimated cost of the energy efficiency improvement portion of requested loan: 15. Does project incorporate or expand environmentally innovative projects or practices? If yes, describe. Business case required? Yes* No Estimated cost of the environmentally innovative portion of requested loan: 16. Does the project integrate or expand long term environmental or financial reliability and viability, or use an approach, not included in other green project categories above? Yes* No Estimated cost of the environmental or financial reliability and viability portion of requested loan: *If yes, submit business case with application. 10-WQ-008 Last Updated: 1/16/2015 5
6 WATERBODY 17. Provide the name, 8 digit Hydrologic Unit Code and location of waterbody receiving discharge Primary affected waterbody: Other affected waterbody: HUC# HUC# GPS Location Latitude: Longitude: 18. Discharge affected by proposed project (check all that apply) Ocean outfall Estuary/Coastal Wetland Surface water (stream, river, lake) Groundwater Land application Other/reuse Eliminates discharge No change/no discharge Seasonal discharge 19. Wastewater Volume: (average dry weather design flow) For current system: For proposed project: Eliminated or conserved mgd mgd mgd 20. Indicate if project will protect or restore the beneficial use of the waterbody. If project provides both, indicate which outcome is primary and which is secondary. (Not all will apply) Protection Restoration Domestic water supply Primary Secondary Primary Secondary Fishing Industrial water supply Boating Irrigation water contact Recreation Livestock watering Aesthetic quality Fish and aquatic life Wildlife and hunting Commercial navigation and transportation Hydropower Information on beneficial uses of Oregon s waters is available at 10-WQ-008 Last Updated: 1/16/2015 6
7 21. Identify other uses project helps to protect or restore. If project results in both, indicate which is primary and which is secondary. Outcomes must be supported by description in #7. (Not all listed outcomes will apply) Infrastructure improvement Regionalization/Consolidation Water Reuse/Recycling/Conservation Groundwater protection Drinking Water Supply (e.g., groundwater source) Other public health/pathogen reduction Wetland Restoration Security Industrial Other (please describe) Protection Restoration Primary Secondary Primary Secondary 22. Project will improve water quality by addressing one or more of the following? (Check all that apply): Temperature Bacteria Dissolved oxygen Nutrients Contaminated sediments Other Toxic substances *Provide documentation, as described in Application Instruction, to support water quality improvement. 23. Is facility currently in compliance? If yes, answer question #24. If no, skip to question # Is facility at risk of noncompliance? If yes, describe how project will ensure continued compliance of facility and how long the solution is expected to maintain compliance. 25. What noncompliance issue (if any) will this project address? Water quality standards Public health Limits for wastewater or stormwater discharge to surface water or groundwater Waste discharge limits for reuse of biosolids or wastewater Describe how project will address indicated noncompliance issue(s). 10-WQ-008 Last Updated: 1/16/2015 7
8 WATER QUALITY/PUBLIC HEALTH BENEFITS 26. If the proposed project is not implemented at this time, are water quality standards likely to be exceeded, or are existing exceedances of the standards likely to worsen? If yes, explain which standard(s) will worsen and provide evidence. 27. Will project improve or sustain aquatic habitat that supports native species or state or federal threatened/endangered species? Which species? Describe how project will contribute to aquatic habitat improvement. Provide evidence, if available: Attach map with project location and habitat clearly indicated. 28. Project will address water quality or public health issue within (check all that apply): Federally designated Wild and Scenic River Federally designated sole source aquifer State designated scenic waterway Lower Columbia River Tillamook Bay estuary River designated under OAR (Three Basin Rule) Wetland or riparian area listed by the state or a local government None of the above Attach map with project location and proximity to waterbodies clearly indicated. 29. Project supports the implementation of which of the following: Existing TMDL Projected TMDL DEQ Water Quality Status and Action Plan Designated groundwater management area declared under ORS 468B.180 Other qualifying plan None of the above Explain which TMDL, Plan or GWMA and how project will support the plan: 10-WQ-008 Last Updated: 1/16/2015 8
9 30. Does project provide performance based water quality improvements? If yes, describe activities that support these water quality improvements and how these activities will provide reasonable assurance that the project will continue to function over time. Include documentation, if available. EDUCATION AND INVOLVEMENT 31. Explain long-term planning effort applicant is using to ensure the life and maintenance of the project. 32. Describe on-going educational or outreach components of project. 33. Does the project incorporate partnerships or support through one or more of the following: In-kind support; other funding sources; partnerships with organizations (governmental, tribal, non-governmental); other? If yes, describe. 10-WQ-008 Last Updated: 1/16/2015 9
10 SCHEDULE AND BUDGETING 34. Project Schedule: Estimated design start date: Estimated construction start date: Estimated project completion date: Estimated initiation of operations date: 35. Project Costs and Funding: TABLE A. PROJECT BUDGET Total Project Budget Administration and Legal Contingency Preliminary Expense CWSRF Eligible Land and Right of Way CWSRF Ineligible Land Basic Engineering Other Engineering Project Inspection Construction Other: Total Costs CWSRF Loan Funded Costs TABLE B. FUNDING SOURCES DEQ Clean Water State Revolving Fund Loan IFA Community Development Block Grant IFA Special Public Works Grant and/or Loan IFA Water/Wastewater Grant and/or Loan USDA Rural Development Grant and/or Loan General Obligation Bonds Revenue Bonds Local Funds (note source of funds): In-Kind Assistance Other: Total Funding (must equal total costs in Table A) Funding 10-WQ-008 Last Updated: 1/16/
11 36. Existing Sewer-Related Debt Service (before CWSRF project funding): General Obligation Bonds Sewer Revenue Bonds Other Debt Current Balance Interest Rate Year Issued Term (Yrs) Annual Payment Bond Rating 37. Loan Structure: Revenue-Secured Loan - Coverage Factor and Reserve Pair Debt Service Coverage Factor: Loan Reserve Percentage: General Obligations (GO) Bonds - Date of Voter Approval: Rated Revenue Bonds Alternative Loan 38. Service Area Data: Population served by the current system: Number of Equivalent Dwelling Units (EDUs): Population served by the proposed project: 39. Sewer Systems Costs, Revenues, and Residential Rates Before Project (current situation - most recent year data available) Sewer System Expense $ Sewer System Revenues: Residential: $ # Connections average monthly rate: $ Non-Residential: $ # Connections Project Completion (projected) Sewer System Expense $ Sewer System Revenues: Residential: $ # Connections average monthly rate: $ Non-Residential: $ # Connections 10-WQ-008 Last Updated: 1/16/
12 SUPPORTING DOCUMENTATION Exhibits There are supporting documents that, when applicable, are required for submittal to DEQ along with the CWSRF Application in order for the project to be considered for a loan. They include but are not limited to: Audited financial statements Approved planning document Current copy of approved budget Environmental review document A sewer use ordinance Land use compatibility statement Land use compatibility statement Documentation of a user charge system Pre-award compliance report Plans and specifications Value engineering study Inter-agency agreement Consult the Checklist of Application Requirements for Point Source Design or Construction Projects for a complete list of required documents. Applicants should realize many of the documents require reasonable preparation time to complete and it is strongly recommended that applicants discuss these required documents early in the application process. The checklist can be located at CERTIFICATION The public agency or applicant certifies that: Clean Water State Revolving Fund loan proceeds will be used only for the project described in this application. The public agency or applicant will comply with all applicable rules and laws. The public agency or applicant will obtain all applicable local, state, and federal permits, approvals, and licenses, and comply with their terms and conditions. The undersigned is duly authorized to request this loan on behalf of the public agency. The public agency or applicant declares under penalty of law that all facts given and information attached are true and correct. The public agency or applicant authorizes DEQ to verify all information. Authorized Signature Date Typed Name and Title LGIP Account Number (for processing loan disbursements) Return the completed application to your DEQ Project Officer. A complete list of Clean Water State Revolving Fund staff is located at 10-WQ-008 Last Updated: 1/16/
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