Tribal Drinking Water Grant Program

OMB Control Number = 2090.NEW, Expiration Date = mm/dd/yyyy

Tribal Drinking Water Grants: Workplan Proposal Form

General Instructions: Please use this form to provide EPA with information about your proposed project workplan. EPA’s Tribal Drinking Water funding programs are administered by EPA Regional Offices, each of which have unique grants administration processes, procedures, and timelines. EPA Regional Offices may have developed Region-specific supplementary instructions to aid applicants in completing this form. Please refer to any Region-specific instructions provided and contact your EPA Regional Office point of contact if you have questions about completing or submitting this form.

Burden Statement

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2090-NEW. Responses to this collection of information are mandatory [40 CFR Part 35, 2 CFR Parts 200 and 207]. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 – 5 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

1.

Project Name

2.

Applicant/ Grantee Information

1. Applicant Name:

2. Applicant Address:

3.

Contact Information

1. ^Name:

2. Title:

3. Address:

4. Phone Number:

5. ^Email:

4.

Funding Program Identification

Please indicate the Tribal Drinking Water Funding Program(s) to which you are applying:

5.

Project Location and Population Served by Project

6.

Water Utility Information

1. Does this project benefit an existing Public Water System(s)?

If yes, please provide detailed information describing the public water system(s) that will benefit from this project. At a minimum, please include:

2. Public Water System ID Number:

3. Water System Owner:

4. Is this a Community or Non-Community Water System?

5. Is this a For-Profit or Non-Profit Water System?

6. Total population served by the public water system:

7. Total number of service connections:

8. Does the utility have a certified water operator?

9. Does the utility have an annual operating budget?

10. Does the utility have an accounting system that records, tracks, and reports the public water system’s revenues and expenses separate from other program activities?

11. Other relevant information, including details about the drinking water supply and source(s)

7.

Project Need

Describe why this project is necessary. If applicable, provide as much detail as possible on the public health risk(s) that this project addresses. If this project addresses specific drinking water contaminants, please identify the contaminant(s):

8.

Project Description Summary

9.

Environmental Results, Outputs, and Outcomes

10.

Project Components and Milestones Schedule (see example schedule for Construction Projects)

11.

Project Cost Summary

Estimated Total Project Cost:

Estimated Cost Breakdown by Project Component:

Project Component	Estimated Component Cost	Notes
	$
	$
	$
	$
	$
	$
	$

12.

Other Project Details

Please provide other relevant details about this project, including:

1. Has a Preliminary Engineering Report (PER) been completed for this project (If yes, submit with proposed workplan)?

2. Has an Environmental Information Document been completed for this project (If yes, submit with proposed workplan)?

3. Has a Design document been completed for this project (If yes, submit with proposed workplan)?

4. Project partners:

5. Please provide information about any other EPA or non-EPA funding sources for this project (includes funding that has been provided for the project in the past or funding that entities have committed to contributed to the project):

13.

BIL Funding for Emerging Contaminants and Lead Service Lines

1. Is the primary purpose of this project to address an Emerging Contaminant (any contaminant listed on any of EPA’s current or past Contaminant Candidate Lists (includes PFAS)?

2. Does the project involve the identification or replacement of lead service lines?

Signature of Person Certifying this information is accurate___________________________

Name and Title of Person Above____________ Date___________