2011/02/09 Council Agenda Packet

7 '- Is this a consolidation/restructuring project?(restructuring/consolidation projects ❑YES 0 NO are defined as taking over non-compliant,failing or struggling water systems) Do you have a current DOH approved Water System Plan,Small Water System 0 YES 0 NO Management Program or Amendment that includes the proposed project? If no,did you submit one with this application or by March 1,2011? ❑YES ❑NO Is your engineering and design work completed? 0 YES ❑NO Have you submitted the required construction documents and project report to your DOH 0 YES ❑NO regional office?You must coordinate with your DOH Regional Office to determine if these documents are required for your project. Have you secured any required easements and right-of-way? 0 YES ❑NO Do you have sufficient water rights for your project? 0 YES ❑NO AYES 0 N Do you have source meters on all existing water sources? Does the water system have service meters on all existing services?If no,your project ❑YES 0 NO must include service meter installation—see guidelines for more information). Does the project include service meter installation? Cl YES 0 NO Are you asking for a service meter exemption?(see guidelines for eligibility) If so, YES ❑NO attach metering exemption request letter to application. Will you be using any other funding sources for your project?If yes, please list funding ❑YES 0 NO sources and amounts: Funding Source: Local Funds for Preliminary Engineering, Design Amount 515,004 Funding Source: Amount: Funding Source: Amount: Funding Source: Amount: Funding Source: Amount: Do you want to be considered for Restructuring Bonus Points? (see guidelines) If yes,list the names and PWSID#'s for each system being taken over and restructured. ❑YES 0 NO Name: PWSID#: Name: PWSID#: Name: PWSID#: Name: PWSID#: DOH Form 331-201 (Rev.10110) ffi