sustainable infrastructure planning projects (sipp ...proposal / solution (attach additional pages...

775 Summer St NE Suite 200

Salem OR 97301-1280

Sustainable Infrastructure Planning Projects (SIPP) Application

Section I A: Applicant

Organization Name Organization Type

Street Address Mailing Address

Office Phone Web URL

Section I B: Contacts Main Contact Secondary Contact

Section I C: Project Overview

Project Name

Opportunity / Problem (Attach Additional Pages if Necessary)

Name

Title

Email

Phone

Name

Title

Email

Phone

Proposal / Solution (Attach Additional Pages if Necessary)

Note: For “Seismic Risk Assessment and Mitigation Plan” project deliverable mark N/A and use section VIII to describe the planning project.

Project Activity Work Plan

EstimatedStart Date

Estimated End Date

Estimated First Cash Reimbursement Request Date

Section I D: Project Details

Detailed Planning Project Description (Attach Additional Pages if Necessary)

Estimated Planning Project Completion Date

Address 1

Address 2

Zip Code

Location Description Attach a Project Map or Site Plan (Attachment A).

Section I E: Project Budget (Maximum SIPP Award $20k)

Budget Line Item SIPP Funds

Other BizOR Funds

Non-BizOR Funds

Total

Planning

Other: Other: Total Project Costs

Prepared By:

Name Title

Organization Date

Section I F: Financing Sources

Source of Funds Amount Status Date Funds Committed or Expected

SIPP (SDWRLF) Applicant Funds Other Funds: Other Funds: Other Funds: Other Funds: Total

For Other Non-Business Oregon Funds, attach Letters of Commitment (Attachment E)

Project Location

Congressional District

State House District

Senator Name:

Representative Name:

Congressperson Name:

State Senate District

City State

Section II: Program Requirements

A. Does the planning project evaluate a compliance issue?

Note: Attach a copy of compliance documentation (Attachment F)

C. Compliance Category: Select all that apply.Arsenic Copper Lead Nitrate Nitrite

D. Federal Funding Accountability and Transparency Act (FFATA)

Yes No

Yes No

Officer Name Officer Compensation

Yes No

B. If you answered “yes” to II A above, describe Compliance Type

Notice Date:

If yes, select an item below.

Yes No

Total Coliform Disinfection & Disinfectant By-Product Radionuclides State Regulations Capacity

ConditionConsolidation

Residential Wells

Did your organization receive over 80% of their revenue fromfederal awards last year?

Security

Does the Public have access to executive compensationinformation via SEC or IRS reports?If yes to each of the above in question D, complete the tablebelow:

Section III: Applicant Details

A. DUNS Number: Federal Tax ID Number:

Date SAM (System for Award Management) Registration Expires:

B. Is the Applicant currently or expected to be a party to anyIntergovernmental Agreements related to the Project?(e.g. Intertie or delivery to another water system, et cetera)If yes, attach a copy (Attachment G) of the agreement(s).

C. Does the Applicant request any information in this Application Yes No be excluded from public disclosure? If yes, describe:

D. Has the Applicant ever defaulted on debt? If yes, explain: Yes No

E. Is there any actual or pending litigation that could impair the Applicant’s Yes No ability to repay debt? If yes, explain:

F. Has the Applicant adopted a budget for the current fiscal year? Yes No If no, explain:

G. Are the Applicant’s audited financial report for the 3 most N/A Yes No recent fiscal years available on the Secretary of State website?If no, explain

H. For those applicants not required to submit financial reports to N/A Yes No the Secretary of State, does alternate financial documentation(e.g. 3 year of tax returns, other budgetary or financial spreadsheets,et cetera) exist? If no, explain:

Section IV: Water System DetailsA. Water System Identification Number (PWSID):B. Does the water system have a current Water System Master Plan?

If no, explain:

C. Will the Applicant operate and maintain the water system?If no, attach a copy of the operating agreement (Attachment H).

D. Does the water system have a current Operations,Maintenance & Replacement (OM&R) manual or plan?If no, explain:

E. Does the water system use asset management tools as partof its operation, maintenance and replacement planning? If yes, describe:

F. Does the water system have a meter(s) at the water supply source(s)?If no, explain:

G. Does the water system require meter installationon all service connections?

H. Does the water system have meters installed on all service connections?If no, percent not metered: %If no, explain:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

OR

I. Does the water system have an operations program to read Yes No and maintain the required source and service connection meter(s)?If no, explain:

J. Does the water system bill its customers based on water usage? Yes No If yes, attach a copy of the current rate schedule (Attachment B).If no, explain:

K. Does the water system have a formal process for adopting Yes No water user rates?If yes, attach a copy of the most recently adopted rateresolution or ordinance (Attachment C).If no, explain:

Section V: Summary of connections, Usage and Populations Served

User Current Connections

Future (20 years) Connections

Current Annual Usage (in gallons)

Residential Commercial Industrial Other Totals

Number Service by All Residents Permanent Residents Connections System Project

Section VI: Private Water Systems

A. Public Utility Commission (PUC) regulation level: Service Rates N/A

B. Type of business (Pick only one): Association Limited-Liability Corp. Non-Profit Corporation Sole-Proprietorship Cooperative

For-Profit Corporation Partnership Other, Specify:

Attach documentation detailing establishment of water system (Attachment I). C. Date business filed / formed:

D. Date present operations commenced:

E. Are any legal actions pending against the water system or principals? Yes No If yes, provide details:

F. Has the Applicant, or principals, formed a business which ceased to Yes No exist in less than two years from commencing operations, filedbankruptcy, or experienced foreclosure, repossession, debt judgment,or criminal penalty within the last seven years?If yes, provide details:

G. For each principal in the business provide the following:Name Title Address % Owned

Section VII: Project Deliverable

A. Project Deliverable:Note: If “Seismic Risk Assessment and Mitigation Plan” complete Section VIII below to verifyeligibility.

B. Last significant capital improvement completed:

C. Will the results of this plan lead to future drinking water infrastructure Yes No project(s) and/or contribute to an existing project?If so, describe:

Section VIII: Seismic Risk Assessment and Mitigation Plan Note: Only complete this section if a “Seismic Risk Assessment and Mitigation Plan” project deliverable is selected. Eligibility Determination

Yes No

Yes No

Yes No

Yes No

A. Is the water system identified in this application undertakinga full Water Master Plan submittal?

B. Does the water system serve between 300 and 3,300 connections?

C. Is the water system subject to the Seismic Risk Assessment and MitigationPlan requirements for master plans under OAR 333-061-0060(5)(a)(J)?This includes water systems fully or partially located in areas identified asVII to X, inclusive, for moderate to very heavy damage potential using theMap of Earthquake and Tsunami Damage Potential for a SimulatedMagnitude 9 Cascadia Earthquake, Open File Report 0-13-06, Plate 7published by the State of Oregon, Department of Geology and MineralIndustries.

D. Would the proposed Seismic Risk Assessment and Mitigation Planencompass a 50-year planning horizon?

If “No” is selected for any of the above questions, the water system is ineligible for “Seismic Risk Assessment and Mitigation Plan” SIPP funding.

If "Yes" is selected for all of the above questions, answer E-H under Seismic Study Approach on Page 10.

https://www.oregon.gov/oha/PH/HEALTHYENVIRONMENTS/DRINKINGWATER/PLANREVIEW/Documents/seismic-map.pdf

Study Approach

E. Describe the approach that would be taken to identify critical facilities (i.e., critical waterinfrastructure) capable of supplying key community needs, including fire suppression, health and emergency response and community drinking water supply points. Describe any resulting work products (Attach additional pages if necessary).

F. Describe the method by which the consequences of seismic failures for each critical facility wouldbe identified and evaluated. Describe any resulting work products. (Attach additional pages if necessary).

G. Describe how the findings from E. and F. above would be used to make recommendations tominimize water loss from each critical facility, capital improvements, or recommendation for further study or analysis. Describe any resulting work products. (Attach additional pages if necessary).

H. Cost of Seismic Risk Assessment and Mitigation Plan portion of the Master Plan:

Note: Attach an itemized engineer’s cost estimate for the full Water Master Plan which clearly describes the work to be accomplished and breaks out the cost of the Seismic portion (Attachment J).

Section IX: Application Attachments

Required Attachments Attachment A: Project Map or Site Plan (Section I D) Attached? Attachment B: Current Rate Schedule (Section IV J) Attached? Attachment C: Most Recently Adopted Rate Resolution (Section IV K) Attached?

Required if Applicable & Optional Attachments Attachment D: Addition Planning Project Overview & Details Attached? (Sections I C, I D, Section VIII) Attachment E: Funding Letters of Commitment (Section I F) Attached? Attachment F: Copy of Compliance Documentation (Section II B) Attached? Attachment G: Intergovernmental Agreement (Section III B) Attached? Attachment H: Operating Agreement (Section IV C) Attached? Attachment I: Document(s) Verifying Establishment of Private Attached? Water System (Section VI B) Attachment J: Engineers Water Master Plan Cost Estimate – Required Attached? for Seismic Risk Assessment and Resilience Plan (Section VIII H) Attachment K: Signature Authority Documentation (Section X) Attached?

Section X: General Certification I certify to the best of my knowledge that all information contained in this document and any attached supplements is valid and accurate. I further certify that to the best of my knowledge:

1. The application has been approved by the governing body or is otherwise beingsubmitted using the governing body’s lawful process, and

2. Signature authority is verified.Check one:

Yes, I am the highest elected official. (e.g., Mayor, Chair or President)

No, I am not the highest elected official so I have attached documentation thatverifies my authority to sign on behalf of the applicant. (Document such as charter,resolution, ordinance or governing body meeting minutes must be attached.)

Business Oregon will only accept applications with proper signature authority documentation (Attachment K).

Signature Date

Printed Name Printed Title