Financial Assistance Application Page 7 of 11 General Information Package (Rev. 10/2020) Drinking Water State Revolving Fund
General Application Package
☐ PLANNING ☐ X CONSTRUCTION
I. APPLICANT INFORMATION
Applicant Name:
Street Address: City: State: Zip+4 Code:
Mailing Address: City: State: Zip+4 Code:
Applicant Total Population:
Applicant Total Number of Service Connections:
Current year median household income (MHI) :
Congressional District(s):
State Senate District(s) :
State Assembly District (s):
Data Universal Numbering System (DUNS) No.: Federal Tax ID No.:
Authorized Representative Name: Title:
Phone No.: Email Address:
Contact Person Name:
Phone No.: Email Address:
Local Counsel Name:
Phone No.: Email Address:
II. PROJECT INFORMATION AND PROPOSED SCHEDULE
Project Title:
Project Descri ption and Objectives :
Current Status of Plans & Specif ications , Percent (%):
Estimated A mount of Financial Assistance Requested:
Total Project Cost (If More Than the Amount of Assistance Requested):
Water Supply Permit Number (Attachment G1):
Population Served by Project :
Estimated or Actual Date
Currently Estimated
Project Schedule: Adopt Environmental Documents :
100% Plans & Specif ications :
Start of Construction/Implementation :
Complete Construction/Implementation :
Financial Assistance Application Page 8 of 11 General Information Package (Rev. 10/2020) Drinking Water State Revolving Fund
Consultation with Other Agencies
Please list other federal and state agencies that have been involved in this project (e.g. planning, CEQA/NEPA consultation, f unding, etc.), their contact inf ormation if known, and estimated dates f or resolution of any issues.
Partnering Agencies
Please list all ot her agencies that have an interest in this project , their contact inf ormation if known, and brief descriptions of their roles.
Other Funding Sources
List any other f unding sources f or this project, along with the amount of addition al funding and date of availability III. MANAGERIAL INFORMATION
Classification of Water System:
Community Non-transient non-community Transient non-community Not currently classif ied as a public water system
Indicate the Ownership of the Water System (check all that apply):
§ Include the ownership documentation (See instructions f or further information) (label as Attachment G2)
Public Ownership
Municipality County Agency Special District State Agency
Public School Other:
Private Ownership
Corporation Limited Liability Corporation Partnership Sole Proprietorship Non-prof it Organization Other:
§ If the water system is privately -owned, indicate the name and title of the individual with authority to engage the water system in a DWSRF financing agreement. Click or tap here to enter text. § If the Water System is a Municipality, is the Water System a Charter City? Yes No § If the Water System is a Corporation, Limited Liability Company, or Partnership, complete the f ollowing:
A. California Secretary of State Entity Number:
Financial Assistance Application Page 9 of 11 General Information Package (Rev. 10/2020) Drinking Water State Revolving Fund
B. Status with Calif ornia Secretary of State:
Active Suspended Forf eited Dissolved Is the Water System regulated by the California Public Utilities Commission (CPUC)? Yes No If yes, the Water System must obtain CPUC approval. Attach a list and a description of all matter(s) relating to your Water System that are currently pending bef ore the CPUC (label as Attachment G3).
List the names, titles and duties of key officers and attach an organization chart providing this information (label as Attachment G4).
Is there any litigation pending relative to the operation of the water system or the proposed project? Yes No
If yes, attach a description of the litigation and the potential costs ( label as Attachment G5).
Is the Water System leasing land or major water system facilities? Yes No If yes, describe the terms of the lease or attach a cop y of the lease agreement (label as Attachment G6). (NOTE: If the lease is critical to the location or operation of the proposed project f acilities, the term of the lease must be equal to or greater than the loan repayment period.)
Include a general map of the service area/boundaries (label as Attachment G7):
[For Construction Projects Only] Does the Water System have a contract with a private firm or another agency for the operation of the facility to be financed? Yes No If yes, provide the name of the firm or agency and term (in years) of the agreement and attach a copy of the agreement (label as Attachment G8)
Water Conservation
1. Are you an urban water supplier as def ined in Water Code Section 10608.12?
YES NO
Urban water suppliers must submit one of the following (Label as Attachment G9):
Water Conservation Program
Signed the Memorandum of Understanding regarding urban water conservation in Calif ornia Urban Water Management Plan per Water Code Section 10653 Financial Assistance Application Page 10 of 11 General Information Package (Rev. 10/2020) Drinking Water State Revolving Fund
2. Attach Certif ication f or Compliance with Water Metering Form (label as Attachment G10).
IV. ATTACHMENTS
G1 – Water Supply Permit and Enf orcement Orders
G2 – Ownership Documentation
G3 – CPUC Documentation (if applicable)
G4 – Organization Chart
G5 – Pending Litigation (if applicable)
G6 – Lease Agreement (if applicable)
G7 – Service Area Map
G8 – Operating Agreement
G9 – Urban Water Supplier Conservation Document (if applicable) G10 – Certification of Compliance with Water Metering Form (if applicable) G11 – Potential DWSRF Flags Worksheet
CERTIFICATION AND SIGNATURE OF AUTHORIZED REPRESENTATIVE To the best of my knowledge and belief , I certify that I am authorized to submit this applicat ion; the inf ormation provided in this application is tr ue and correct; the documentation has been duly authorized by the governing body of the applicant; and the entity possesses the legal authority to apply f or the financing and enter into a f inancing agreement with the State Water Resources Control Board and to f inance and construct the proposed f acilities.
Name of Authorized Representative: Title:
Signature of Authorized Representative: Date:
Attachment G10