Application Date:
West Basin Municipal Water District
Water Bottle Filling Station Funding
Program FY 2021-2022
Water Bottle Filling Station Funding Request Application Point of Contact Name:
Title: Agency/Department:
Phone Number: Email Address:
Applicant’s Legal Entity Name:
Mailing Address Street: City: Zip:
Indicate Type of Applicant:
Describe the location of the proposed site (ex. indoor/outdoor, building type).
Describe the exposure and approximate number of people that pass through the proposed location.
Describe your need, reasoning and interest for a water bottle filling station.
Describe the estimated project timeline (if known) for this project.
CONTACT INFORMATION
PROJECT INFORMATION
Identify the person who will be responsible for administering the funding agreement.
Special District School District City
Application Date:
Where will the filling station unit be installed?
O Indoors (up to $1,000) O Outdoors (up to $2,000)
Does your agency agree to pay for the installation and maintenance costs associated with the unit? O Yes O No
Are there any additional approvals (city codes/requirements) that must be pursued in order to install the unit? O Yes O No
Project Cost Report
Type of Cost
Applicant
Budget
1 Administrative $
2 Labor (i.e. installation) $
3 Materials/Supplies $
4 Equipment* $
5 Other $
Total Project Cost
$
*West Basin will only provide funding for Water Bottle Filling Station equipment costs Funding Request: Fill in Only One of the following options Indoor Filling Station Grant Request: $ Not to exceed $1,000 Outdoor Filling Station Grant Request: $ Not to exceed $2,000
COST INFORMATION
OTHER INFORMATION
Application Date:
I hereby certify that I am duly authorized by the applicant’s governing body to apply for funding from West Basin Municipal Water District for the project described in this application. I further attest that the information provided in this application is accurate to the best of my knowledge.
Authorized Representative’s Signature Date
Authorized Representative’s Name (print) Title
APPLICATION CERTIFICATION
ATTEST:
____________________________________
Eleanor Manzano, City Clerk
APPROVED AS TO FORM:
___________________________________
Michael W. Webb, City Attorney