DELAWARE HEALTH AND SOCIAL SERVICES DIVISION OF PUBLIC HEALTH OFFICE OF DRINKING WATER DRINKING WATER STATE REVOLVING FUND LOAN PRE-APPLICATION Delaware Health and Social Services Division of Public Health Office of Drinking Water 655 Bay Road, Suite 203 Dover, DE 19901 Phone (302) 741-8630 • Fax (302) 741-8631 The Drinking Water State Revolving Fund provides Public Drinking Water Systems with low-interest loans, for up to 20 years, for infrastructure improvement projects. Included in this package are preliminary instructions and the forms required to apply for a loan. Eligibility: All community water systems, both publicly and privately owned, and non- profit non-community water systems are eligible. The entity applying for the loan must own the system if the water system is currently in operation. If the application is for a proposed water system, the entity applying for the loan must hold the Certificate of Public Convenience and Necessity for the area. Federally owned and State owned systems are not eligible to receive assistance. Fees: A 1% Loan Origination Fee will be charged on all loans, is due at loan closing, and may not be included in the loan. Application Ranking: All pre-applications received will be ranked according to the information provided herein. Projects will be funded in ranking order until funds are exhausted. Please ensure that all questions are answered completely and accurately. A separate application form must be submitted for each project. If you submit applications for more than one project, make sure to use different project titles for each. Due Date: Submit the Original plus 2 Copies of each Pre-Application in the provided envelope on or before September 15, 2007. Pre-applications postmarked or hand- delivered after this deadline will not be eligible. The applicant certification portion of this application requires an original authorized signature; therefore, faxed and electronic submission cannot be accepted. Questions? Contact Heather Warren at the Office of Drinking Water (302) 741-8585. Email Heather.Warren@state.de.us to request an electronic version of this Instructions Section I-General Information Public Drinking Water System Indicate the name of the drinking water system where the project will be located. Project Title Indicate the name of the project. If you submit applications for more than one project, make sure you use different titles for each. Applicant’s Name and Address Indicate the entity who is applying for the loan for this project. Also include information regarding the mailing address, telephone number, fax number, and email address, of the person(s) or company applying for the assistance on behalf of the water system. Primary Contact Include information regarding the mailing address, telephone number, fax number, and email address, of the person our office should contact for more information. If this is the same information as in number 1, please state “Same as Above”. Project Contact or Consulting Engineer Include information regarding the mailing address, telephone number, fax number, and email address, of the project contact or consulting engineer of the company assisting with the project. Legal Owner of System: Indicate the entity who is the legal owner of the system. Also include the mailing address, telephone number, fax number, and email address. Ownership Information Indicate ownership and information regarding Certificate of Public Convenience and Necessity (CPCN). Section II- Project Information Project Ranking Information Mark all areas that apply to the project’s purpose. Include all information regarding the project that will assist our office in accurately evaluating and ranking the project. **Only mark deficiencies and violations that are existing or have occurred within the preceding 5 years AND will be remediated with this project. Do not check off possible deficiencies or violations.** All scoring will be based on the Project Priority Criteria, which is included in this packet. The scoring prioritizes projects in order of their importance in preserving public health, maintaining compliance with the State and Federal Regulations, and the financial need of the community. Brief Project Description Provide a brief description of the project. For example: * Replace deteriorated water mains on Smith Street—3,000 feet of 8 inch pipe. * Replace 30 lead goose-necks. * Install nitrate removal system on Well #1. * Replace finished water storage tank. (10,000 gallons) with a 20,000-gallon tank due to deterioration of 30-year-old tank and unable to meet peak demand. Description of Problems to be Solved by Project Include all information regarding the problems within the water system that should be solved by the project. Make sure to also reference the project that remediates this problem under Section II, page 6. For example: * Eliminate broken mains and possible causes for bacteriological public notices last year (replace deteriorated main). * Move into compliance with the Lead and Copper rule (removal of lead goosenecks). * Removal of enforcement status for nitrates above 10 mg/L (installing nitrate removal system). * Eliminate possible cause for bacteriological public notice, increased water clarity, and eliminate water shortages during peak hours (replacing storage tank). Proposed Project Time Frame Indicate the time needed for each portion of the project. Section III- Financial Information Project Financial Summary Complete all expense lines for the project. Section IV- Project Benefits Description Federal programs are facing increasing scrutiny to measure program effectiveness. It is essential to be able to provide federal oversight agencies and decision-makers with credible information regarding the benefits of the DWSRF program. Therefore, beginning in July 2007, the EPA is requiring DWSRF fund recipients (applicants) and funding agencies (DHSS) to provide more specific project information. The objective is to succinctly capture the public health benefits of projects in terms that are meaningful and easily understood to outside observers (e.g., Congress, public). Complete all applicable sections. Section V- Applicant Certification Applicant’s Certification Insert the name and signature of the person legally authorized to sign, date, and submit this loan pre-application on behalf of the owner(s) of this water system. Loan Pre-Application Form State of Delaware Drinking Water State Revolving Fund Section I- General Information Public Drinking Water System: Project Title: Applicant’s Name and Address: (P.O. Box or Street, City & Zip Code) Name: Address: Phone: Fax: Email: Primary Contact (Authorized Official): Name: Address: Phone: Fax: Email: Project Contact (Consulting Engineer): Name: Company: Address: Phone: Fax: Email: Legal Owner of System: Name: Address: Phone: Fax: Email: Ownership Information: Does the entity applying for this DWSRF Loan own the water system? ____ Yes ____ No If “NO,” please list owner of the water system: Does the entity applying for this DWSRF loan hold the CPCN for the area in which the water system is located? ____ Yes ____ No If “NO,” please list who holds the CPCN for this area: Section II- Project Information Check only EXISTING problems to be remediated by this project. Proposed project will eliminate a water quality deficiency: Acute: ___ E. coli ___ Nitrate ___ Nitrite Non-Acute: ___ Total Coliform Bacteria ___ Volatile Organic Chemicals (VOCs), including MTBE ___ Total Trihalomethanes (TTHMs) ___ Synthetic Organic Chemicals (SOCs) ___ Trace Metals ___ Unregulated VOCs ___ Unregulated SOCs ___ Turbidity ___ Radiologicals ___ Lead/Copper Secondary Standards: ___ Iron ___ Trace Metals (such as Manganese, Silver, Copper) ___ pH ___ Chloride ___ Total Dissolved Solids ___ Sulfate ___ Taste ___ Odor ___ Color Proposed project will eliminate a water quantity deficiency: Acute: ___ System water pressure less than 25 psi ___ Water shortages – lack of adequate supply Chronic: ___ Water shortages – lack of adequate storage ___ Water shortages – during peak demand ___ System water pressure greater than 100 psi Proposed project will eliminate treatment and/or design deficiency: (Please list all deficiencies to be remediated by this project) Proposed project will eliminate a security deficiency: ___ Treatment Plant ___ Storage Site ___ Distribution System ___ Source ___ Electronic Proposed project will allow for returning to compliance with the following Safe Drinking Water Act (SDWA) Regulation(s): ___ Lead/Copper Rule ___ Surface Water Treatment Rule ___ Stage 1 Disinfectants/Disinfection Byproducts ___ Phase I, II, or V ___ Total Coliform Rule ___ Interim Enhanced Surface Water Treatment Rule ___ Radionuclides ___ Long-Term I Enhanced Surface Water Treatment Rule ___ Filter Backwash Rule ___ MTBE Primary Standard ___ Arsenic Proposed project will eliminate a compliance or enforcement status with the Office of Drinking Water. ___ Significant Non-Compliance ___ Active Bilateral Compliance Agreement ___ Alternate Contaminant Level ___ Active Administrative Compliance Order Proposed project will allow for compliance with the following future SDWA Regulation(s): ___ Groundwater Rule ___ Radon ___ Sulfate ___ Long-Term II Enhanced Surface Water Treatment Rule ___ Stage II Disinfectants/Disinfection Byproducts Rule Proposed project will result in regionalization: ___ Consolidation of multiple non-complying water systems ___ Consolidation with one non-complying water system ___ Consolidation of complying water systems ___ Service to areas of existing private wells with water quality deficiencies ___ Service to areas with existing private wells ___ Emergency interconnection with another Public Water System List all consolidated systems and/or areas with private wells to be included with this project: Type of public water system: ____ Municipally-owned Community ____ Community ____ Non-transient Non-community ____ Transient Non-community Location of public water system: ____ New Castle County ____ Kent County ____ Sussex County Type of ownership: ____ Public ____ Private for Profit ____ Private Non-profit Current population served by water system:_______ Final population served:_______ (After project completion) Current number of service connections: _______ Final number of connections: _______ (After project completion) Number of metered service connections: _______ Final number of connections: _______ (After project completion) Do all sources have master meters? ____ Yes ____ No If system charges for water usage, does the rate structure promote conservation? ____ N/A ____ Yes ____ No If “YES”, please briefly describe: _________________________________ Does the water system have an unaccounted water loss of less than 10%? ____ Yes ____ No If “YES,” please briefly describe process to account for all water: Identify the water system’s licensed drinking water operator and provide license number. Name: _____________________________ License # ________________ If there are several operators, please list the Direct Responsible Charge, as specified in Delaware Regulations. Does the operator possess all applicable treatment endorsements? Does the water system have a documented maintenance schedule? ____ Yes ____ No If “YES,” please attach. Does the water system implement a Cross Connection Control Program? ____ Yes ____ No If “YES,” please attach. Project description: Summary of proposed project time frame: (Month/Year) Projected funding start date: Completion of planning and design: Bidding period: Construction period: Initiation of operations Other information: Section III- Financial Information Project Financial Summary: Construction $ ________________ Engineering +$ ________________ Other (Contingency) +$ ________________ Estimated total cost of project =$ ________________ Anticipated funds from all other source(s) to be used to finance total project cost Source(s) ______________________________ -$ ________________ Total project cost financed through DWSRF =$ ________________ Section IV- Project Benefits Public Health Problems Identify contaminants of concern: Describe current drinking water system facilities: Note problem(s) that is/are being addressed/corrected/avoided: Describe compliance and enforcement actions and include dates of violations: Drinking Water Source Note source water protection issues: Summarize the status of source water and wellhead protection efforts: Expected Project Benefits (check all that apply) _____ Meet national drinking water standards _____ Eliminate taste/odor problems _____ Provide more reliable water quantity/pressure _____ Enhance system technical, financial, or managerial capacity _____ Improve facility security _____ Improve fire safety _____ Other public health benefits (describe below) Project Demographics-Municipalities Only Describe any important demographic characteristics of the area (examples would be: % of population over 65 years old, % of population under 5 old) Section V- Applicant Certification Applicant’s Certification: ***This section is required and must be completed in order to be eligible for*** ***funding through the DWSRF Program.*** I hereby certify that the information provided in this application and on any attachments to this application is true and correct, to the best of my belief and knowledge. It is understood that the state may verify information and that untruthful or misleading information may be cause for rejection of this application. I certify that I am legally authorized to sign, date, and submit this loan pre-application on behalf of the owner(s) of this water system. The undersigned also agrees to clarify or supplement information pertaining to this application upon request. Signature: Title: Date: Printed Name: 1 Doc. # 35-05-20/08/02/38