DEQ-01-PDG

Grant Application

F1C2

7-1-09

OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY

DRINKING WATER ENGINEERING PLANNING AND DESIGN GRANT FUND

GRANT APPLICATION

Complete the requested information and return to

Brad Cook, Capacity Development Coordinator

Engineering Planning & Design Grant Fund

Water Quality Division, ODEQ

P.O. Box 1677

707 North Robinson

Oklahoma City, OK 73101-1677

(405) 702-8100

APPLICATION DEADLINES

Small community drinking water systems with populations less than 10,000 are eligible to apply. Applications will be accepted each quarter and must be either post marked or received in the offices of DEQ by 4:30 p.m. on each of the following deadlines:

·  September 30, 2009

·  December 31, 2009

·  March 31, 2010

·  June 30, 2010

SELECT TYPE OF DRINKING WATER SYSTEM

Public Trust If application is filed in the name of a public trust (Utilities Authority, Public Works Authority, etc.), the application and resolution must be signed by Chairman of board of trustees and must include copy of trust indenture, declaration of trust, etc. creating the public trust.

Municipality If application is filed in the name of a municipality (Town or City), the application and resolution must be signed by Mayor or Chief Executive Officer and must include a copy of the municipality’s incorporation document organizing and creating the municipality.

Rural Water District If application is filed in the name of a rural water district, the application and resolution must be signed by the Chairman or President of the board of directors and must include a copy of the County Commissioner’s Order incorporating and organizing the district.

APPLICANT INFORMATION

A.  System Name: / D. PWSID No.:
B.  Address: / E. Phone:
F. Fax:
C.  County / G. E-mail address:
H.  Applicant’s Federal identification Number:
I.  Cite the Authority of Law under which applicant is established:

J.  Applicant’s officers and board members (Name and Office held):

Name / Office Held

K.  Describe the problems of your drinking water system that need to be corrected. Include all current enforcement orders from the Oklahoma Department of Environmental Quality.

L.  Population

M.  If you have an engineer under contract, please provide

Name / Address / Phone number

VERIFICATION

STATE OF OKLAHOMA )

) ss.

COUNTY OF )

I, ______, being first duly sworn and upon oath states: That he or she is the duly authorized representative for the applicant herein; that he or she has read the contents of the within and foregoing GRANT APPLICATION and is familiar with the contents thereof; and that the matters and information therein set forth are, to the best of Applicant’s knowledge and belief, true and correct.

Entity Name:______

Applicant Signature: ______

Applicant Name: ______

Applicant Title: ______

Subscribed and sworn to before me this _____ day of ______, 20___.

______

Notary Public

My Commission Expires:

______

(SEAL)

ATTORNEY’S CERTIFICATION AS TO LEGALITY OF APPLICATION

I, the undersigned, certify that: I am an attorney representing the applicant herein with respect to the foregoing application attached hereto; the applicant is a [CHECK ONE]:

Public trust

Municipality

Rural Water District

Other Public Entity (identify):

Duly organized and existing under the laws of Oklahoma; the applicant possesses full power and authority to acquire, complete and operate the project described in this application; and this application has been lawfully and effectively authorized and executed as the valid action of the applicant.

______

Attorney at Law

Printed name: ______

OBA No: ______

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