NHDES-W-07-047

Boat Sewage Pumpout/Dump Station Funding

Application for New Construction or Repair

Watershed Management Bureau

Clean Vessel Act Program

50CFR85

Instructions: For new construction or replacement (major repair) of a pumpout or dump station, please fill out the form below as completely as possible. If any section is unknown, simply leave it blank or describe the situation briefly. If the project is approved, draft documents for a grant will be sent to representative for review before being finalized. Any missing information can be entered at that time.

Date:

Marina Information

Marina Name: ______

Mailing Address: ______

Marina Physical Address/Coordinates (if different):______

Town, State, Zip: ______

Public Phone Number:______

Website Address:______

Fee to be charged if grant is approved (must be $5 or less):______

Depth of water at the pumpout location:______

Are there any access constraints to the marina?Yes______No

Will there be a portable toilet disposal (dump station)?Yes______No

Will there be off season operation (not typical in NH)?Yes______No

Grant Information

Name of representative to sign grant documents:

Who will authorize the above listed representative? Vote by group, such as board members

Owner/President

Other:

Cost Estimate (can be a rough estimate but be as accurate as possible):

Name of Marina’s Insurance Company:

Email Address (at which to send grant documents):

Notable Requirements for Construction/Repair of Pumpout and Dump Stations:

  1. The acceptance of Clean Vessel Act (CVA) funding bears a requirement that the pumpout or dump station be made available to the public. Station cannot be limited to members only regardless of whether other amenities are restricted use.
  2. Organizations applying for funds must verify means of waste disposal prior to finalizing grant documents. This may include receiving permissions from the town for use of sewer line, permissions from treatment facility to discharge boat sewage, verifying septic system size is adequate for increased use, or installing a holding tank.
  3. Funds are granted as a reimbursement only. Organizations must provide for the initial payments to all vendors and submit a request to the NH CVA program staff. Per grant regulations, up to 75% of the total project cost may be reimbursed. The remaining 25% is the required match from the grantee.
  4. No expense incurred before the approval date of a grant from NHDES will be approved for reimbursement. Please wait until the CVA program staff indicates to you that the grant was approved before making any purchases.
  5. It is the responsibility of the grantee to follow all federal, state, and local regulations including obtaining any permits that are needed.

If you have any questions, please do not hesitate to contact CVA staff at or (603) 271-8803.

Agreement

As a representative of the above-namedorganization, I hereby apply for federal grant fundingunder the NH CVA Program.By signing below, I acknowledge that approval is contingent upon availability of funds, review by NHDES, and compliance with the grant scope of services. Further documents will be requested prior to final approval.

______

Signature Printed Name

Email Completed Form To: R Mail To:

Ph. (603) 271-2457

2016-08-31 ` Page 1 of 2