Environmental Protection Agency, Region 9

Drinking Water Tribal Set-Aside Grant

Project Proposal Form

Directions: See Section IV.B of the Guidelines

Project Name
Applicant Information / Tribe Submitting Proposal ______
Did you receive Drinking Water Tribal Set-Aside money for this project this year?______
Did you receive drinking water state revolving fund money for this project this year?______
Contact Information / Name______Title______Email______
Address______Fax Number______
______Phone Number______
Service Area Information / Total Population Served______Total number of connections______
Number of meters______Percent of connections metered______
Is billing based on meter readings?______
Number of tribal people served by project(s)______
Number of non-tribal people served by project(s)______
Water Utility Information / Project Location______
Water System Owner______
Will the proposed project be owned by a different entity? If yes, please explain______
______
Is this a Public Water System?______
If Yes:What is the Public Water System ID Number?______
Is this a Community or non-Community Water System?______
Is this a For-Profit or Non-Profit Water System?______
Does this system have a certified water operator (Please include certification level)?______
Water Supply Information / How many storage tanks are connected to the system?______
What is the capacity of each tank (in gallons)? ______
______
How many wells are connected to the system?______
What is the maximum capacity of each well (in gpm)? ______
______
How many pressure zones are in the system?______
Describe each pressure zone (i.e. which tanks are used for each zone). ______
______
Are there water outages?______If so, how often? ______
What is the reason for the outages? ______
Other Background Information / Describe any existing water conservation measures ______
______
Does the Tribe and/or water utility have a source or wellhead protection program?______
Is the Tribe or system in the process of implementing one of the above programs?______
Is the proposed project a consolidation project?______If so, how many systems will be
consolidated?______What are their populations?______
What is the per capita, per day water consumption in gallons/person/day of treated water for the water system? ______
Project Need / Describe why this project is necessary______
______
______
______
______
Project Description / Description of Proposed Project______
______
______
______
Project Cost / Estimated Total Project Cost $______
Cost Breakdown by Health Category:
Health Corresponding ProjectEstimated. # ConnectionsPopulation
CategoryComponent Component Cost Benefiting Served…...
1)______$______
2)______$______
3)______$______
4)______$______
Committed Funding / Have other entities committed to contribute funding for this project?______
If so, describe commitment______
Have you applied for funding from other agencies?______
If so, which agencies?______
Project Status / Preliminary Engineering Report Complete? YesNo If Yes, please attach
Environmental Information Document Complete? YesNo If Yes, please attach
Design Complete YesNo If Yes, please attach

Signature of Person Certifying this information is accurate______

Title of Above Person______Date______