"V -~-^-' v'X'v>1 / -"i **.''' 'i ' V -"t '*".-' -s i \/M T^:--' -s i / .t ป' s i v^i > 'N.' ">-/ -^ k" *' ^'"ป-"^''
ฃ United States EPA 540 K-93-004
^ Environmental Protection Publication 9230.1-09B
ij. Agency PB93-963353
V September 1993
v . Office of Solid Waste and Emergency Response
s w Superfund Technical
} Assistance Grant (TAG)
v Handbook:
The Application Forms
with Instructions
xtoV"
e^".r-^\ ''} v^ir'-x I/'C-VC-<,'r<.-<''-s.-<,r-s1 X
^^^SS^^ii^^^^^i^t^^
vAVA^r^.l^-W^'f^A^
-------
-------
SAMPLE APPLICATION DOCUMENTS WITH STEP-
BY-STEP INSTRUCTIONS
Detailed instructions to assist you in completing the TAG application
forms are included in this booklet, along with sample completed forms
and blank forms. The samples show the questions filled in with the "an-
swers" of a hypothetical group called the Woodtown Landfill Coalition.
To simplify your work, EPA has filled in those items on the grant forms
that are the same for all TAG applicants. The instructions offered are for
those items that you need to complete.
You will find the following sample documents and forms in this booklet:
Letter of Intent (LOI).
Application for Federal Assistance:
General Information, Signature, and Certification (SF 424).
Budget Information (SF 424A).
Assurances (SF 424B).
Project Narrative Statement.
Certification Regarding Debarment, Suspension, and Other Respon-
sibility Matters (EPA Form 5700-49) (needed only if your group is
seeking a grant of $25,000 or more).
Drug Free Workplace Certification.
Certification Regarding Lobbying (needed only if your group is
applying for technical assistance at multiple sites and could poten-
tially receive more than $100,000 in total grant funding).
The blank forms can be used to complete your TAG application. Before
filling out your application, you may find it useful to photocopy the
blank application forms to create a draft set. If questions arise as you
complete these forms, please do not hesitate to discuss them with your
Regional TAG Coordinator.
-------
H'1 III'" '"LI Jl: in1 ""ill"'! VII lililllllllillllP'iiiliinl'i' SliUfi'lll'''!^!!'''!'!!'*!"!!
ll1 ' ' '-i'1: '"in, :' i T '!'"
SAMPLE LETTER OF INTENT (LOI)
-------
Woodtown,Landfill Coalition
Main Street
Woodtown, CT 06898
May 3, 1993
TAG Project Officer
Superfund Management
EPA Region 1
Mail Code: HPC-CAN7
John F. Kennedy Federal Building
Boston, MA. 02203
Dear Sir/Madam:
This letter has been prepared by the Woodtown Landfill Coalition
to announce this group's intention to apply for a Technical As-
sistance Grant. The Coalition, which is composed of the
Woodtown Citizens Task Force and the Smithtown Outing Club,
plans to use any awarded grant funds to obtain assistance in in-
terpreting technical information generated during the Superfund
cleanup process at the Woodtown Landfill site in Litchfield
County, Connecticut. Please send an application and other rel-
evant materials to the Woodtown Landfill Coalition, in care of
Pat Jones, at the address listed above. The group hopes to file-
its application in July 1993.
Sincerely,
Pat Jones, Executive Director
Woodtown Landfill Coalition
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APPLICATION FOR FEDERAL ASSISTANCE
GENERAL INFORMATION, SIGNATURE, AND CERTIFICATION (SF 424)
Section IApplicant/Recipient Data
2. Applicant's Application Identifier
Date: Write the current date.
Identifier: Leave Blank.
3. State Application Identifier
Date and Identifier: Leave Blank.
" ' ,' " ,. " ': ! . ! "
4. Federal Identifier
Date and Identifier: Leave Blank.
5 Applicant Information: List the name and address of your group and the name and tele-
phone number of a contact person who would be able to supply additional information if
necessary. "Organization unit" is not applicable to TAG applicants.
6 Employer ID Number: This number is obtained from the Internal Revenue Service, using
Form SS-4 ("Application for Employer Identification Number'"). If you have applied for
the number but have not yet received it, write "Applied For" next to the boxes.
|
8. Type of Application: Check the appropriate box (either "new" or "continuation").
11. Title of Project Enter the name of the Superfund site for which the grant will be used.
12. Areas Affected by Project: List the municipality or town(s), county (ies), and state(s) adjacent
"to, encompassing, and affected by the site.
" : ' } "' " ' "
13. Proposed Project
Start Date: Ask your EPA Regional Office the date that funding is likely to be
approved if you receive an award. Write in this date or the date you wish to begin receiv-
; ing funds, whichever is later.
Ending Date: Estimate the length of the project period, and add that to the start
date to calculate the ending date. This period cannot exceed 36 months (three years).
14. Congressional Districts:
a. Applicant: ' Write the district number(s) and state abbreviations) of the
member(s) of Congress who represents the area where the offices of the incorporated
group are located.
b. Project: Write the district number(s) and state abbreviationฎ of the mem-
ber(s) of Congress representing the area that encompasses the site.
15. Estimated Funding: Enter the amount of funds needed for the first budget period, indi-
cated in the" Statement of Work. The amount in line "a," EPA's proposed funding, can-
not be more than 80 percent of the amount in line "f," the total funding, and initially
cannot be more than $50,000.
, . i ; | :'! i
16. Intergovernmental Review: Call or write your state's intergovernmental review contact to find
out how and where to submit your application for review. Enter the date that the appli-
cation was made available to file appropriate state contact under "a. 'YES." If there is no
review process in your state, check the second box under "b. NO."
17. Federal Debt: Check either "Yes" or "No? and attach an explanation if "Yes."
18. Applicant Certification: Fill in "a"-"c". Your group's project manager must sign and date
"d" and "e."
-------
APPLICATION FOR
FEDERAL ASSISTANCE
OMB Approval No. 0348-0043
|2. DATE SUBMITTED
I 7/10/93
Applicant IdenuRor
t. TYPEOFSUBMISSION:
Application .
Npn-Conilfueuwt
C Non-Conitructian
3. DATE RECEIVED BY STATE
Slate Appllcawn Idanofier
4. DATE RECEIVED BY FEDERAL AGENCY
5. APPLICANT INFORMATION
UgalNam.: Woodtown Landfjll Coalition
NA
Nama and wlaplton* numbw at person 10 bซ eantacltd on mantra involving this
application (&>*** axiti
Pat Jones (203) #^
atom off, county. ซ"* Jซrf i
Main Street
Woodtown, CT 06898
I-itchfieid County
8. EMPLOYER IDENTIFICATION NUMBER fฃIN):
|x |x|- |x |x I x|x |x I xlx I
B. TYPE OF APPLICATION:
K Now C Conunuavon D Rov
ivtuon. tBinf aooropnat* leitai(a) in txปni424(flEV.*.ซl
b*tf try OM3 eiteulir A-103
-------
, I1 '",
BUDGET INFORMATION (SF 424A)
Section A Budget Summary
1. Grant Program, Function, or Activity
Enter the name of the Superfimd site on line i.
2.-5.
Write "See Detailed Budget in Project Narrative Statement, Section 2(B)" in
line 2 across columns (d)-(g) (budget information is requested in Project Narrative
Statement).
Section B Budget Categories
6.a-6.kand7.
Write "See Detailed Budget in Project Narrative Statement, Section 2(B)" in
line 6.b across columns (2)-(5).
-------
OMB Approval Ho. 03 o ^ , * i !,ป , \
|7. Program Income
Piavlnn Edition uubli
Estimated Unobligated Funds
Federal
(c)
S
$
Non-Federal
M
$
See. detailed I
Section 2 IB)
$
New or Revised Budget
Federal
(e)
$
udget in Proje
$
Non-Federal
(1)
S
ct Narrative '
$
IS;SSSSSrlP?ง't!SNfiiSy65SR*iSt83Wl6?^^S^WSSS5SSfj^S^^^^%
.Technical ._.
(1*Aseictancc
$
GRANT PROGRAM. FUNCTION OH ACTIVITY
in
t
See detailed 1
Section 2(B)
$
131
$
udget in Proje
$
_ . .
Ml
S
ct Narrative i
S
Total
(9)
$
tatement
$
P^^^^^M'pi^^r^f^
Total
IS)
t
tatement ,
$
- #K * " v ;" '* ;* ' ,
p [S
Authorized lor Local Reproduction
$
$
Standard Form 424A (Rtv. 4.92]
PraaeritMd fay OMB Circular A-102
-------
- - 1' I ..... !-1 ........ '!.!'!'i ' ...... if"! .......... ,. - - - - T^"1
](;'' "',']. ..... i "I ''"I"]!!1"!'!! .............. I ..... ..... III!!: ...... I"".;!':'*! ..... ". -"/: ...... n.:' ;;. i " ..
Section F Other Budget Information
23. Remarks
Do not complete.
-------
(a) Grant Program
Pechnical Assistance at; Woodtown Landfill Silte
See detailed
budget in Pro
set narrative
Statement, Saction 2(B)
12. TOTAL(sumolซnes8-11)
13. Federal
18,544
4,000
6,744
3.600
4.200
14. NonFederal
4,636
1-.000
1.686
900
.1,050
(a) Grant Program
(b) First
(c) Second
(d) Third
(e) Fourth
'Technical assistance Grant at;Woodtown
none
17Landfill site
20. TOTAL (sum ol linos 16-19)
21. Direct Charges:
22. Indirect Charges:
23. Remarks:
Authorized (or Local Reproduction
-------
, li,,!' 1"'!>-
ASSURANCES (SF 424B)
This form contains the regulations, policies, guidelines, and requirements to
which your group must adhere. You should read these carefully and then your
group's project manager should sign at the bottom of the page. Be sure to submit
this sheet with the rest of your application package.
OMB Approval No. 0348-0040
ASSURANCES NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response.^including
time for reviewing instructions, searching existing data sources, gathering and "ป"ป"ป"* "ซ*ป ^f^
completing and reviewing the collection of information. Send comments regarding the burden estimate or any ซhe
aspect of This collection of information, including suggestions for reducing this burden, to the Offcce of Management
and Budget, Paperwork Reduction Project (0348-0040). Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND"T TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program. If you havei questions;, please^omact
the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant I certify thac the applicant:
I. Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay ihe non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.
2. Will give the awarding agency, the Comptroller General
of United States, and if appropriate, the Slate, through
any authorized representative, access to and the right to
examine all records, books, papers, or documents related
to the award; and will establish a proper accounting
system in accordance with generally accepted
accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.
4. Will initiate and complete the work within the
applicable time frame after receipt of approval of the
awarding agency.
5. Will comply with the Intergovernmental Personnel Act
of 1970 (42 U. S. C. ง4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the nineteen statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C. F. R. 900, Subpan F).
6. Will comply with all Federal statutes relating to
nondiscrimination These include but are not limited to:
(a) Title VI of die Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin: (b) Title IX of the Education
Amendments of 1972, as amended (20 U. S. C. ง1681-
1683, and 1685-1686), which prohibits discrimination
on the basis of sex: (c) Section 504 of the Rehabilitation
Act of 1973, as amended (29 U. S. C. ง794), which
prohibits discrimination on the basis of handicaps: (d) the
Age Discrimination Act of 1975, as amended (42 U. S. C.
ง6101-6107), which prohibits discrimination on the
basis of age: (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255),os amended, relating to
nondiscrimination on the basis of drug abuse; (0 the
Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616). as amended, relating to nondiscrimination
on the basis of alcohol'abuse or alcoholism; (g) งง523 and
527 of Ihe Public Health Service Act of 1912 (42 U.S.C.
290 dd-3 and 290 ee-3). as. amended, relating to
confidentiality of alcohol and drug abuse patient records;
(h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C.
ง3601 et seq.), as amended, relating to nondiscrimination
in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and 0)
-------
9. Will comply, as applicable, with the provisions of the
Davis-Bacon Act (40 U.S.C. งง276a to 276a - 7), the
Copeland AM (40 U.S.C. งง276c and 18 U. S. C.
งง874), and the Contract Work Hours and Safety
Standards Act (40 U.S.C. งง327-333). regarding tabor
standards for federally assisted construction
subagreements.
10. Will comply, if applicable, with flood insurance
purchase requirements of Section 102(a) of the Rood
Disaster Protection Act of 1973 (P.L. 93-234) which
requires recipients in a special flood hazard area to
participate in ihe program and to purchase flood
insurance if (he total cost of insurable construction and
acquisition is S 10,000 or more.
II. Wilt comply with environmental standards which
may be prescribed pursuant to the following: (a)
institution.of environmental quality control
measures under the National Environmental Policy
Act of 1969 (P.L. 91-190) and Executive Order (EO)
11514; (b) notification of violating facilities pursuant
to EO t I?38;.(c) protection of wetlands pursuant to EO
11990; (d) evaluadon of flood hazards in floodptains in
accordance with EO 11988: (e) assurance of project
consistency with the approved State management
program developed under the Coastal Zone
Management Act of 1972 (16 U.S.C. 5งI451 et seq.):
(Q conformity of Federal actions to State (Clear Air)
Implementation Plans under Section I76(c) of the
Clear Air Act of 1955, asamended (42 U.S.C. งง 7401
et seq.); (g) protection of underground sources of
drinking water under the Safe Drinking Water Act of
1974. as amended. (Pi.. 93-523); and (h) protection of
endangered species under the Endangered Species Act
of 1973. as amended. (PX. 93-205).
IZ Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. งง1271 et seq.) related to protecting
components or potential components of the national
wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966. as amended (16 U.S.C. 470), EO 11593
(identification and protection of historic properties), and
the Archaeological and Historic Preservation Act of 1974
(16U,S.C.469a-letseq.).
14. Will comply w(ih PJL 93-348 regarding the protection of
human subjects involved in research, development, and
related activities supported by this award of assistance.
15. Will comply with ihe Laboratory Animal Welfare Act of
1966 (RL. 89-544. as amended. 7 U.S.C. 2131 ซ seq.)
pertaining to the care, handling, and treatment of warm
blooded animals held for research, teaching, or other
activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. งง 4801 et seq.) which
prohibits the use of lead based paint in construction or
rehabilitation of residence structures.
17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act of 1984 or.OMB Circular No. A-133, Audits of
Institutions of Higher Learning and other Non-profit
Institutions.
18. Will comply with all applicable requirements of all other
Federal laws, executive orders, regulations and policies
governing this program.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
*$&ฃ tywJH-s
TTOE
Executive Director
APPLICANT ORGANIZATION
Woodtown Landfill Coalition
DATE SUBMITTED
7/10/93
Slindinl Form 4MB (Rn>. 4/92) luck
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PROJECT NARRATIVE STATEMENT ' ' "
'ป:" " V1 ''' ': ;; " '" i i' ' ':
The Project Narrative Statement consists of two sections. The first section,
"Group Qualifications," is used by EPA to obtain information about your
group's eligibility, characteristics, and plans for using grant funds.
The form for the Project Narrative Statement follows a question and answer
format which is, for the most part, self-explanatory. To illustrate the type of
information sought, the sample application shows the questions filled in with the
"answers" (in bold, italic type) of a hypothetical group called the Woodtown
Landfill Coalition. Additional instructions are given where applicable.
12
-------
PROJECT NARRATIVE STATEMENT
Section 1 (Croup Qualifications)
A. Group Eligibility
1. Do any of the following categories apply to your group? no (yes/no) If the
answer is yes, check the categories below that apply and provide a detailed
explanation.
Are any members of your group potentially responsible parties (PRPs)?
Was your group established by a PRP?
Was/is your group sustained by a PRP?
_Was your group established by, or is it presently sustained by, any of the following:
a corporation that is not incorporated for the specific purpose of repre-
senting affected individuals at the site?
an academic institution?
a political subdivision?
Does anyone in your group have financial involvement in a PRP (as other than
an employee or contractor)?
2. How many members are in your group? 705 Is it made up of a coalition of
groups? yea (yes/no) If so, how many, and how did the groups come
together? If not how was your group formed?
The Woodtown Landfill Coalition is composed of members from two groups
the Woodtown Citizen Task Force of Woodtown, CT, and the Smithtown Outing
Club of Smithtown, CT. The main concern of the Woodtown Citizen Task Force,
formed in 1986, is health effects resulting from contamination at the site. The
Smithtown Outing Club, founded in 1965, organizes a variety of outdoor trips
around Litchfield County. The Club's main concern is the effects of contamina-
tion from the Woodtown Landfill site on the surrounding environment. Since
both groups require technical assistance, they have chosen to form an incorpo-
rated coalition for the purposes of this program.
-------
PROJECT NARRATIVE STATEMENT, cont.
Section 1Group Qualifications
- ' ; I . . .... .
,i
Bl. Administrative and Management Capabilities
The "attached bylaws" referred to in the sample answer are mentioned for the
sake of instruction only, andhave not actually been appended to this example
because they will vary on a case-by-case basis. Your group should include such
bylaws when submitting your application if you are incorporated.
' ' ' i . 'i ' : i ,;:.'!
" ' . , II , : " 'I t
B2. Resources for Project Completion
The value of equipment, such as an adding machine or typewriter supplied by
your group, may be counted as an in-kind contribution. However, only that portion
of the property's use directly attributable to the TAG project counts as an in-kind
contribution.
The value of donated space, such as an office for the technical advisor(s), may be
considered an in-kind contribution, but it must not exceed the fair rental value of
comparable space in a privately-owned building in your community. If donated
space is used for purposes other than the TAG project, only the portion associated
with the TAG project counts as an in-kind contribution.
14
lijllil :, 1.1
-------
Section 1, cont.
B. Responsibility Requirements
1. Administrative and Management Capabilities: Please briefly describe the
organizational structure of your group in the space below. (Describe roles and
responsibilities of members, particularly members who will be responsible for
financial management of the grant and directing the activities of the contractor.)
Both the Woodtown Citizen Task force and the Smithtovm Outing Club have oper-
ated as nonprofit organizations for at least five years and have existing administra-
tive structures that oversee and guide their activities, the Woodtown Landfill Coa-
lition is also nonprofit, and will be managed by a four-person executive committee
composed of the two presidents and the two treasurers of the respective groups. One
member of the executive committee has been designated as Executive Director of the
Coalition, The Executive Director will be the group's designated representative for
the purpose of signing all documents related to the grant. The Executive Committee
will direct the technical advisor and oversee the entire project. The two treasurers
will be responsible for all financial oversight. The attached bylaws provide addi-
tional details about the administrative structure of the Woodtown Landfill Coalition.
2. Resources for Project Completion: What resources are available to your group
to help complete the TAG Project? (Include any plans that your group has for
in-kind contributions or for fund-raising and obtaining cash.)
To complete our technical assistance project, we will require the services of a techni-
cal advisor for three years. At this time, the total estimated budget for the entire
project will be $62,500. Of this amount, the federal share will be $50,000. We will
match the federal share of $50,000 with $12,50020 percent of the total project
costwith a combination of cash and in-kind contributions. The cash portion will
come from annual dues and fund-raising activities such as the Smithtovm Canoe
Rally and Woodtown Recycling Drive. In the past three years, we averaged $1,500,
collectively, from these fund-raising activities. We also have received about $500 in
donations in each of those years. In-kind contributions will come from donated
meeting space, planning activities, time spent managing the technical advisor, ac-
counting services, writing and editing services, and time required to put out mail-
ings. A local businessman (a member and an officer of the Woodtown Citizen Task
Force) will donate meeting space for use by the Coalition on an as-needed basis
throughout the life of the project. A certified public accountant will donate services
to provide accounting assistance to the Coalition. A local free-lance writer and a
local newspaper editor will design, write, and edit a newsletter devoted solely to the
site and technical assistance project. Attachment 13, provides a detailed budget, in-
cluding a breakdown of federal and matching shares.
-------
PROJECT NARRATIVE STATEMENT, cont.
Section 1Group Qualifications
' ' ... '" , !' ,1 , f "i'i'i, v ' j. 'i ' '' ' I ' "" / ป' I' Si
B3. Performance Record
The sample answer refers to Attachment I.E., "Proposed Schedule and Costs
for Technical Advisor." The Attachment illustrates one way of displaying the tasks,
timeframe, and budget. TAG applicants may display this information in a different
way if they choose.
Hi
16
i 11-
-------
Section 1, cont.
3. Performance Record: Please describe your group's past performance with
satisfactorily completing projects and contracts. (If your group has no past
experience, EPA will evaluate the description, budget, and schedule you
provide in Section 2 of this application.)
Although neither of the founding groups (Woodtown Citizen Task Force and
Smithtown Outing Club) nor the new Coalition previously have received federal
funds, we believe the group can satisfactorily complete the proposed TAG
project. Both groups have successfully organized and earned out fund-raising
and community events, entailing organizing and budgeting activities. The
Statement of Work (Attachment 1^..) included in this application describes in
detail our proposed plan for use of a technical advisor's services.
Attachment 1.3., "Proposed Schedule and Costs for Technical Advisor," ties our
Statement of Work to our budget. The primary areas of past involvement are
health and environmental concerns.
4. Accounting and Auditing Procedures: What procedures does your group
plan to use for recordkeeping and financial accountability related to the
grant? Please identify the member of your group who will maintain your
financial records.
Our financial management system complies with generally accepted accounting
procedures. We will establish and maintain a separate bank account and a gen-
eral ledger for the sole management of the TAG. The two treasurers on the Ex-
ecutive Committee, Mary Jones and Fred Smith, will maintain all financial
records related to the grant. These records will be stored in a central file in the
^sarne office where the Coalition meetings will be held. A phone log will be
maintained by the Coalition's officers. In addition, contractors will be expected
to keep a telephone log and other records of their activities and expenditures.
A member of the Woodtovm Landfill Coalition, originally from the Smithtown
Outing Club, is a certified public accountant and has volunteered to assist in the
financial oversight of grant funds. He will advise the group on completing fi-
nancial reports required by EPA and the state. In addition, an outside account-
ing fiim will be brought in to perform an independent audit every other year, as
required by federal regulations in the event that the group receives $25,000 or
more in reimbursements from EPA in any given year.
-------
'X
PROJECT NARRATIVE STATEMENT, cont.
.J..-' ' . '" . ; , .. ,.;. :.,. iui'i ; , ' .:. ;' ,.
B5. Incorporation
You may meet the incorporation requirement'by stating that your group, if not
'' already incorporated, has filed the necessary forms for incorporating.
Once your group is informed that it has been "chosen to receive a grant, you
must affirm that your group has filed the necessary papers for incorporation with the
state. However, on or before your first request for payment, you must submit to
EPA documentation (such as a letter from the state) that your group has been
incorporated officially by the state.
If your group is incorporated for some other purpose, it must be reincorpordted
for the purpose of administering a TAG.
The letter and bylaws referenced in the sample answer have not actually been
appended to this example because they will vary from case to case. They are referred
to for illustration purposes only.
,; i; ' ." ;,,, i!i!' ... " ... , !l ' ' " . ' . '"I
, B6. Drug-Free Workplace
,,! This statement must be completed in order to comply with the Anti-Drug
Abuse Policy Act of 1988.
11 ini ' ' ' " :i
,i
- - i
I
Cl. Health Considerations
Explain whether your group members are subject to demonstrable health
threats, whether actual or potential, or to a threat that group members reasonably
believe to be substantial. However, your inability to provide documentation of
health problems related to the site will not necessarily prevent you from receiving a
grant, provided the other evaluation criteria are met.
18
-------
Section 1, cont.
5. Incorporation: Is your group incorporated specifically for the purpose of ad-
dressing problems at this site? _yes_ (yes/no) If not, what steps is your group
taking to incorporate for grant-related purposes?
The Woodtown Landfill Coalition filed for and received approval from the state of
Connecticut for incorporation as a non-profit organization. Attached is a copy of
the letter from the state approving the group for incorporation. In addition, a copy
of the group's bylaws has been attached. This document provides a description of
the administrative structure of the Woodtown Landfill Coalition and general group
goals.
6. Drug-Free Workplace Policy: Does your group promise not to engage in illegal
drug-related activities while carrying out activities using TAG funds? yes (yes/no)
C. Group Issues and Objectives
1. Health Considerations: How many group members have experienced health
effects from contamination at the site? unknown Describe actual or potential
health threats the site poses to individual group members and the efforts members of
your group have undertaken to resolve or make known these health concerns.
Concent aboutcontaminated private wells and possible health effects resulting from
the contamination atthe site led to the initial formation of the Task force. As ex-
plained in a private sampling report, residents' well water continues to lie undrink-
able due to its strong odor, brownish color, and unpleasant taste, which tite Task
Force believes to be solely caused by contamination from the Woodtown Landfill
site. Several residents have reported to the Task Force that they have experienced
mysterious skin rashes after bathing in well water and are concerned about their
health. As a result, community members have had to resort to using bottled water
for nearly four years. ERA is considering members' requests for an alternate water
supply after the Agency has completed its sampling atthe landfill The Woodtown
Citizen Task Force, at a member of the Woodtown Coalition, wants to ensure spe-
cifically 1hat all potential health risks that are related to the site are investigated
thoroughly and that the remedial action selected will restore the quality of com-
munity well water supplies.
-------
PROJECT NARRATIVE STATEMENT, cont.
20
-------
Section 1, cont.
2. Consolidation/Representation: Describe the number and diversity of affected com-
munity organizations and individuals represented by your group, highlighting the ways
in which your group represents individuals affected by the site.
The Woodtown Landfill Coalition has a diverse membership that represents much of
the community's interests and concerns about the Woodtown Landfill site. Over 75
percent of the members live within a five mile radius of the site. Coalition members
believe that this organized effort will positively affect both members of the group and
individuals in the community by providing a single contact from which community
concerns can be addressed. The Coalition itself does not have a long history with the
Woodtown Landfill site, but its composite organizations have been active in dealing
with site issues since the site was listed on the NPL in 1986.
3. Tasks for Technical Advisors: Please describe how your group intends to use your
technical advisor to interpret technical Superfund information.
The primary purpose of the tasks to be performed by the technical advisor is to help
members of the Woodtown Landfill Coalition better understand the technical informa-
tion, data, reports, designs, and oral presentations provided by EPA and the state in
the course of studying and conducting remedial activities at the Woodtown Landfill
site. By interpreting, analyzing, and evaluating the information, the technical advisor
will aid our group in commenting more productively and effectively on remedial ac-
tivities at the site. The ultimate goal of the technical assistance project is to help us
help EPA clean up our drinking water and restore the Rolling River to its previous rec-
reational uses. A more detailed description of the tasks to be performed by the techni-
cal advisor is given in tile Statement of Work (Attachment I A.) and in the Proposed
Schedule of Tasks and Costs for Technical Advisors (Attachment 13.).
4. Information Sharing: How does your group intend to share information collected
with grant funds with the larger community?
To keep community members informed of activities at the Woodtown Landfill site, the
Woodtown Landfill Coalition will produce six issues of a newsletter containing infor-
mation generated by the technical advisor(s). 320 copies of this newsletter will be
printed for each issue: 200 copies will be distributed by hand to interested community
members and 120 copies will be mailed directly to Coalition members and the local
press. In addition, all final documents produced by technical advisor(s) will be sent to
EPA to be placed in the information repositories established for the site at a location
accessible to interested community members (the Woodtown Public Library). To en-
courage community involvement in activities related to the site, the Coalition will
make all of its general monthly meetings open to the public. Additionally, before
EPA's public meeting on the Feasibility Study, the Coalition will hold a community
forum to brief the public on the technical advisor's findings. The coalition will adver-
tise the meeting by putting an ad in the local newspaper.
-------
PROJECT NARRATIVE STATEIViENT, corit.
C5. Economic/Environmental Considerations
Under this item, you should fry to establish whether your group members may
be subject to:
A demonstrable economic threat.
Impairment of the group's use and enjoyment of the environment, whether
actual or potential.
A threat that is reasonably believed to be substantial.
If you are unable to provide documentation of economic or environmental
problems related to the site, you may still be able to obtain a grant, provided other
criteria are met.
Section 2 Statement of Work for the Technical Advisor
The second section of the Project Nfarrativ'e Statement is the Statement of
Work for th'e technical advisor(s). In this section, your group describes how a
grant award" would be used with respect to Superfund technical milestones (for
example, review of the Remedial Investigation Report) and provides your
proposed budget.
1 . " ' f ',, '. i
To help determine projected tasks for your advisor and a tentative schedule
in preparing the Statement of Work, you are encouraged to review the pamphlets
and fact sheets on the Superfund and TAG Programs. Also, review the "Super-
fund TAG Handbook: Applying for Your Grant," which discusses the role of the
technical advisor(s), and the sample Statement of Work included in this booklet.
For each task indicated in the Statement of Work, you will need to estimate the
amount of time to be allotted to your technical advisor(s).
I
A. Statement of Work
This item requires a succinct explanation of what you plan to have your
technical advisor(s) do at each stage of the site cleanup process. Be as complete as
possible. Attachment l.A. of the sample application shows one way of providing a
Statement of Work. You may use a different format to provide this information if
' you wish. You should show estimates of the advisor's time to conduct his/her
services during each phase of the cleanup process and the products you expect the
advisor to provide.
22
-------
Section 1, cont.
5. Economic/Environmental Considerations: How many group members have
experienced economic/environmental impacts from contamination at the site?
a/L_ Please describe the actual or potential economic harm or loss of environ-
mental amenities the site has imposed on individual group members, and efforts
group members have undertaken to resolve or make known these concerns.
Members of the Smithtown Outing Club have, since the Club's inception in 1965, ac-
tively organized a variety of swimming, canoeing, fishing, and hiking trips within
Connecticut. Many of these Club-sponsored activities have taken place on or near
the Rolling River. During the last decade, however, contamination from the
Woodtown Landfill site has polluted the river, causing club members to fear swim-
ming or canoeing in the river. Additionally, the state has banned fishing in the river.
The Smithtown Outing Club, as a member of the Woodtown Landfill Coalition,
wants the Woodtown Landfill site cleaned up so that the pollution caused by it will
no longer damage the Rolling River.
A number of economic concerns face many of the members of the Woodtown Landfill
Coalition. The main worry among Coalition members is that publicity about con-
tamination from the landfill may cause the property values of homes with contami-
nated water or with river-front exposure to the Rolling River to decrease signifi-
cantly. As a result, Coalition members support a timely cleanup of the Woodtown
Landfill site before the effects of site contamination scare away potential buyers
and significantly lower property values in the region. Coalition members also have
experienced significant financial burdens from not being able to use their well water.
For example, members must purchase bottled water for drinking and cooking, and
laundry cannot be washed in residential washing machines because the clothes be-
come stained after washing them in the contaminated water.
Section 2 - Statement of Work for the Technical Advisor
A. Statement of Work: Please identify the technical advisorfs)' tasks for each
phase of the Superfund process. For each of these phases, please note what the
technical advisor will do, the estimated amount of time needed to complete
each task, and specific documents, reports, or other tangible work products you
expect the technical advisor to produce.
See Attachment 1A. and I.B.
-------
PROJECT NARRATIVE STATEMENT, cant.
B. Detailed Budget
This item requires you to translate the three-year Statement of Work into dollar
figures. Attachments I.E. and l.C. on pages 35 and 37 show one way of doing this.
The format is optionalthe samples in the attachments are suggestions only.
Attachment I.E. breaks down the general activities from Attachment l.A. into
specific tasks, hours, and dollars. Attachment l.C. summarizes costs by type of
activity and indicates whether they will come from federal TAG funds or the^group's
matching contribution.
The goods and services Usted should include everything you think you will
purchase with grant funds or with your group's matching share. To add items to
the budget later, you will need EPA's written approval.
24
!>I,H< ,, 'i Till !"
-------
Section 2
B. Detailed Budget: Prepare a budget for the technical assistance project. Indicate
the tasks to be completed by the technical advisor, the estimated number of
hours, and the cost for each task (including travel costs, if necessary). Use
footnotes to explain assumptions made .in the budget (such as hourly rate of
advisor or adjustments for inflation). This budget should identify everything that
you expect to purchase with grant funds.
The budget should show the amount of the group's matching contribution
separately from federal funds. Note that the grant funds (usually 80 percent)
plus group contribution (usually 20 percent) must equal the total project costs;
grant funds cannot exceed 80 percent of project costs for any budget period. In
your statement, be sure that you differentiate cash expenditures from in-kind
contributions. Also, include explanations of the assumptions made in calculat-
ing the value of in-kind contributions.
See Attachment l.C.
-------
-i
.. . I "il
,!:!! I InllL
CERTIFICATION REGARDING DEBARMENX SUSPENSION, AND
OTHER RESPONSIBILITY MATTERS (EPA FORM 5700-49)
i
All TAG applicants and some contractor candidates must submit this form.
:"" ':...' ;' I . . ' :";:
On the first line, enter your group's name and. the name and title of your
group's project manager as they appear on page 1 of the main application form
under Items 5 and 18.a.
Your group's project manager must sign and date the second line. If you
cannot sign this certification, check the box and attach an explanation of why you
cannot.
26
-------
:PA Project Control Number
United States Environmental Protection Agency
Washington, DC 20460
Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that It and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared Ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) Have not within a three year period preceding this proposal been convicted of or had a civil judgement
rendered against them for commission of fraud or a criminal offense In connection with obtaining,
attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) Are not presently Indicted for or otherwise criminally or cfvllly charged by a government entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and
(d) Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for causa or default
I understand that a false statement on this certification may be grounds for rejection of this proposal or
termination of the award. In addition, under 18 USC Sec. 1001, a falsa statement may result In a fine of up
to $10,000 or Imprisonment for up to 5 years, or both.
Typed Name & Title of Authorized Representative
Pat Jones, Executive Director
Signature of Authorized Representative
t I I am unable to certify to the above statements. My explanation Is attached.
EPA Form 5700-49 (11-08)
-------
DRUG FREE WORKPLACE CERTIFICATION '
You must sign this certification and "submit it with your TAG application.
In addition, your group must post dhotice stating the drug free policy in
f locations where group members will be doing TAG-related work, such as the office
: or workspace used to administer the TAG.
toil,,
if it
28
i'ili!,i III1 J!!1
-------
Assistance Identification Number:.
CERTIFICATION DRUG FREE WORKPLACE ACT OF 1988
The recipient certifies that it will provide a drug-free workplace by:
(a) publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the recipient's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
(b) establishing a drug-free awareness program to inform employees about:
(1) the dangers of drug abuse in the workplace;
(2) the recipient's policy of maintaining a drug-free workplace;
(3) any available drug counseling, rehabilitation, and employee assistance programs; and
(4) the penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c) making it a requirement that each employee engaged in the performance of the project be given a copy
of the statement required by paragraph (a);
(d) notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the award, the employee will:
(1) abide by the terms of the statement: and
(2) notify the employer of any criminal drug statute conviction for a violation occurring in the work-
place no later than five days after such convictions;
(e) notifying the Award Official within ten days after receiving notice under subparagraph (d) (2) from an
employee or otherwise receiving actual notice of such conviction;
(f) taking one of the following actions, with 30 days of receiving notice under subparagraph (d)(2), with
respect to any employee who is so convicted:
(1) taking appropriate personnel action against such an'employee, up to and including termination; or
(2) requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency;
(g) making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c). (d), (e), and (f).
The recipient shall insert in the space provided below the site(s) for performance of
work done in connection with the specific award
Place of pnrformanca (street address, city, county, state, zip code)
Woodtown Landfill Coalition, Main Street,
Litchfield County. Woodtown. CT 06898 __
Typed Name and Title of Authorized Representative
Pat Jones, Executive Director
Signature of Authorized Representative Daje
-------
) "t";
CERTIFICATION REGARDING LOBBYING -
' ' -.: '.:: ',: >; \ " ". ซ: '!
- This form is required only if your group is applying for technical assistance at
: multiple sites and could potentially receive more than $100,000 in total grant
: funding.
Your group representative must sign and date this form. Submit it to your
Regional Office with the completed TAG application.
'i I"
30
-------
EPA Project Control Number
fiERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS. GRANTS. LOANS. AMD COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, or an employee of a Member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement the undersigned shall complete and submit Standard
Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award of
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making
or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than S10,000 and
not more than $100,000 for each such failure.
Woodtown Landfill Coalition
Pat Jones, Executive Director
Typed Name and Title of Authorized Representative
Signature of Authorized Representative Date
-------
', ,: ","' i1
ii 'i1!'":1" " iii!!'i"i i", i "
''.Ullillil1
I"
-------
Attachment l.A.
Statement of Work
This section provides a detailed description of individual
technical advisor tasks and their purposes. Technical assis-
tance tasks described in this statement of work are based on
conversations with the EPA Regional staff (the Remedial
Project Manager and the Community Relation Coordinator for
the site).
For all reports and reviews completed by the technical advi-
sor, a memo will be prepared for the Coalition's leadership
so that information can be relayed to the membership via the
newsletter. The memo and newsletter also will be sent to EPA
to be placed in the information repository for the site.
Remedial Investigation (Estimate: 160 hours, including one
trip)
The advisor's first task will be to review the RI work
plan, sampling plan, and quality assurance and quality
control (QA/QC) plan. Special attention will be given to
how EPA plans to investigate the migration of contamina-
tion from the Woodtown Landfill site into the Rolling
River. The advisor will be expected to attend and partici-
pate in a proposed meeting between EPA staff and residents
scheduled for the start of the RI. Upon completion of the
RI report, the advisor will be expected to help the Coali-
tion evaluate the results. Another key document to be re-
viewed by the advisor will be the risk assessment (if
available).
Feasibility Study (Estimate: 300 hours, including one trip)
The advisor will complete a detailed analysis of the pro-
posed remedies in the draft feasibility study and then
brief the coalition on its contents. Additionally, the
advisor will prepare a written report to aid the
Coalition's preparation of public comments, specifically
addressing the proposed cleanup measures. The advisor
will make a presentation on his/her findings at a special
community forum held by the Coalition prior to EPA's pub-
lic meeting. The advisor will attend and participate in
EPA's public meeting to be held in Woodtown during the
public comment period. The single, two-day trip during
this period will combine both the Coalition briefing and the
public meeting.
The advisor will be expected to analyze the health assess-
ment thoroughly to ensure that public health is being ad-
equately considered. The advisor will prepare a summary
report on the potential health risks posed by the site and
33
-------
i. i !'"i!* I.
'statement of Work '. (cont. )
how EPA proposes to ' address" these risks. The" advisor "also
will examine the Record of Decision (ROD) and prepare a
memorandum on the chosen method of cleanup. Additionally,
this report will describe how major comments submitted by
the [coalition and the general community were addressed by
\ EPA in the responsiveness summary.
Remedial Design (Estimate: 100 hours)
yhe, technical advisor will be expected to carry out over-
sight 'functionsduring this"stage." The advisor will re-
: viewthe final design to ensure that the design is consis-
tent with the ROD. The advisor will be expected to report
his/her findings in memoranda submitted to the Coalition's
Executive Committee. Excerpts about the progress at the
, , site will"be published in the Coalition newsletter.
Remedial Action (Estimate: 75 hours)
the advisor will be "ex-
Daring the remedial action phase, ... .
pected to review the final inspection report. Within 30
days of the completion of the cleanup, the advisor will
prepare a final report summarizing his/her findings. This
report "will be published in the Coalition newsletter.
ii"
I " film,
,' 1 !'
"
34
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Attachment 1 .B.
PROPOSED SCHEDULE OF TASKS AND COSTS FOR TECHNICAL ADVISOR(S)
YEAR1
YEAR 2
YEAR 3
Schedule/Tasks
Remedial Investigation (Rl)
Review work plan
Issue evaluation memo
Attend Rl klckofl public meeting
Review various Rl reports (e.g., risk assessment,
QA/QC plan, sampling)
Review Rl report and prepare Rl evaluation report
Feasibility Study (FS)
Review health assessment and prepare report
Review draft FS and prepare FS evaluation
Feasibility Study (FS) Continued
Brief Coalition on FS and attend FS meetings
Review Coalition comments on FS
Review ROD and prepare summary memo
Remedial Design (RD)
Review pre-final and final design and prepare
design evaluation memo
Remedial Action (RA)
Review pre-final and final Inspection reports and
prepare cleanup evaluation report
Review
Report
X
X
X
X
X
X
X
X
X
Prepare
Memo/ Attend
Report Meeting
X
X
X
X
X
X
X
X
X
X
#of
Hours
30
8
52
45
85
60
80
15
60
100
75
Cost at
S/hour
$2 280
$1 ,900
$ 60S
$3 952
$3/120
$6,460
$4,560
$6,080
e-t iA(\
#1(11U
$4,560
$7,600
$5,700
Total Cost of Advisor
Travel (site visils and attendance at Woodtown Coalition Meetings and Public Hearings)
Mileage ($055 per mile) m
Lodging and Meals ($100 per diem)
Total Travel Costs
Administrative Costs
Telephone
Postage
Copying
Total Administrative Costs
Total Cost
of Advisor
$12,160
$11,020
$11,780
$7,600
$5,700
$48,260
$500
$400
$900
$500
$200
$140
$840
Total*
of Hours
160
145
155
100
75
635
TOTAL (Federal Share)
$50,000
-------
-------
Attachment 1.B.
PROPOSED SCHEDULE OF TASKS AND COSTS FOR TECHNICAL ADVISOR(S)
Prepare
YEAR1
YEAR 2
YEAR 3
Schedule/Tasks
Remedial Investigation (Rl)
Review work plan
Issue evaluation memo
Attend HI kickoff public meeting
Review various Rl reports (e.g., risk assessment,
QA/QC plan, sampling)
Review HI report and prepare Rl evaluation report
Feasibility Study (FS)
Review health assessment and prepare report
Review draft FS and prepare FS evaluation
Feasibility Study (FS) Continued
Brief Coalition on FS and attend FS meetings
Review Coalition comments on FS
Review ROD and prepare summary memo
Remedial Design (RD)
Review pre-flnal and final design and prepare
design evaluation memo
Remedial Action (RA)
Review pre-final and final Inspection reports and
prepare cleanup evaluation report
Review
Report
X
X
X
X
X
X
X
X
X
Memo/ Attend
Report Meeting
X
X
X
X
X
X
X
X
X
X
*of
Hours
30
25
8
52
45
85
60
80
60
100
75
Costal
$/hour
$2 280
$1,900
$ 608
$3,952
$3,420
$6,460
$4,560
$6,080
$1,140
$4,560
$7,600
$5,700
Total Cost of Advisor
^Mealfisols3 er ^fjdanoe at Woodlown Coalition Meetings and Public Hearings)
LodglngandMeals($100pErdlem)
Total Travel Costs
Administrative Costs
Telephone
Postage
Copying
Total Administrative Costs
Total Cost
of Advisor
$12,160
$11,020
$11,780
$7,600
$5,700
$48,260
$500
$400
$900
$500
$200
$140
$840
Total *
160
145
155
100
75
635
TOTAL (Federal Share)
$50,000
-------
-------
-------
I h?
Attachment l.C.
Detailed Budget for Three Year Budget Period
Federal Share:
Labor (Technical Advisor, and
may include Administrator)
635 hours at $76 per hour $48,260
Travel 900
Other Costs*
Telephone
Postage
Copying, FAX, Printing
500
200
140
Total
Matching Share:
Incorporation
Newsletter (writing, editing,
distribution)
Meeting space ($50 per meeting,
6 meetings per year, or 50x6x3 years)
Accounting, bookkeeping, (1 hr.
per week, 3 years @ $10 per hour)*
Meetings of the Board of Directors
(5 members, 20 meetings, 3 hours
each, $25 per hour per member) * ,
7,500
Total
48,260
900 :
^- - =P5=
f
840-
$50,000
240
r~
2,300;
900
1,560
$12,500
$62,500
i* ;tTotal;adndnistrative costs= '15.8% of fto'tal'budgets.; ซ['
-------
-------
1.
,'" ,, Attachment l.C.
Detailed Budget for Three Year Budget Period
Federal Share:
Labor (Technical Advisor, and
may include Administrator)
; 635 hours at $76 per hour $48,260
Travel 900
Other Costs*
Telephone
Postage
Copying, FAX, Printing
500
200
140
Total
2. Matching Share:
Incorporation
ซ !h : :' in*;?! ' , ' ... i' ...
Newsletter (writing, editing,
distribution)
""Mil i' i ,!" , ' IH ' ,.'
ซ Meeting space ($50 per meeting,
6 meetings per year, or 50x6x3 years)
* Accounting, bookkeeping, (1 hr.
per week, 3 years 8 $10 per hour)*
Meetings of the Board of Directors
(5 mentoers, 20 meetings, 3 hours
each, $25 per hour per member)*
7,500
Total
48,260
900
840
$50,000
240
i, | .L!
2,300
900
1,560
$12,500
$62,500
" r
* Total administrative costs= 15.8% of total budget.
."I1"' "
-------
-------
: h
i'jf
-------
BLANK APPLICATION DOCUMENTS
These are the blank copies of each document you will need to fill out to complete your TAG application.
While these are standard federal grant forms, EPA has developed instruction specifically for TAG applicants
to use in completing these forms. Whenever questions on these forms call for standard answers by TAG
applicants, EPA has supplied the correct response to simplify the application process for you.
Documents you will find in this section include:
Application for Federal Assistance.
General Information, Signature, and Certification (SF 424)
Budget Information (SF 424A)
Assurances (SF 424B)
Project Narrative Statement
Certification Regarding Debarment, Suspension, and Other Responsibility Matters
(EPA Form 5700-49).
Drug Free Workplace Certification.
Certification Regarding Lobbying.
-------
'" ii 'ป
t: '''i.^,.;1
I :ฃ" ',
1
-------
run
FEDERAL ASSISTANCE
I 2. DATE SUBMITTED
Applicant Identifier
1. TYPE OF SUBMISSION: '
Application
C Construction
-------
(if
*').,' "Kit'11!""!'1 . .. Ulll) I ", .Ml
-------
BUDGET INFORMATION - Non-Construction Programs
OMB Approval No. 0348-0044
% ^ f ,
Grant Program
Function
or Activity
(a)
1 Technical
Assistance
2.Gr ant at :
3.
4.
Totals
5 -'-
; .; : :i: :,* ,5'- ^OTtONAซWDai.TSUMHARy'^f , ,, .. !/," * -, .:,,.... c.- ...'...." ' 1
Catalog of Federal
Domestic Assistance
Number
(b)
66-806
Estimated Unobligated Funds
Federal
(c)
$
$
Non-Federal
(d)
$
$
New or Revised Budget
Federal
(e)
$
$
Non-Federal
(0
$
$
Total
(g)
$
$
' , , "' " , SECTIONS -BUDGET CATEGORIES :> % -, ' :- N ,J; " v % ' ^ -
6. Object Class Categories
a. Personnel
b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges (sum of 6a-6h)
j. Indirect Charges
k. TOTALS (sum of 6i and 6j)
Tecnnicai GRANT PROGRAM, FUNCTION OR ACTrvrrv
ID Assistance
$
$
(2)
$
$
(3)
$
$
(4)
$
Total
(5)
$
'' ' " ',->"' '' > - ' ': ,."--',
7. Program Income
Previous Edition Usable
Authori
$
zed for Local Reproc
$
iuction
$
Standard Form 424A (Rev. 4-92)
Prescribed by OMB Circular A-102
-------
(a) Grant Program
" Technical Assistance at:
9.
10.
n.
1 2. TOTAL (sum of lines 8 - 11 )
*:* .''-::.. v.^\: '' y. /i fSEWOti'^fOtlCA3l&> CASHNeEDS '^ , : ^"^^J^' "$^'\fr%& ? J - ' V' j : ' ^ -?
Tolal for 1st Year
$ " "
$
1st Quarter
i
$
2nd Quarter
$
$
3rd Quarter
$
$
4th Quarter
$
$
"'' >; SECTJON EVBUDG^^
(a) Grant Program
6- Technical Assistance Grant at:
7.
8.
Q
!0. TOTAL (sum of lines 16-19)
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11. Direct Charges:
IMA
FUTURE FUNDING PERIODS (Years)
(b) First
$
$
(c) Second
$
$
(d) Third
$
$
(e) Fourth
$
-
$
L : SEaTK>Nf:OTHE8BUD; j , , , ^' ,
22. Indirect Charges:
:3. Remarks:
s = =
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Authorized for Local Reoroduclion
Standard Form 424A (Rev. 4-92) Page 2 c.
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OMB Approval No. U34B-OU4U
ASSURANCES NON-CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including
lime for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management
and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
NOTE: Certain of these assurances may not be applicable to your project or program, If you have questions, please contact
the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant I certify that the applicant:
1. Has the legal authority to apply for Federal assistance
and the institutional, managerial and financial capability
(including funds sufficient to pay the non-Federal share
of project cost) to ensure proper planning, management
and completion of the project described in this
application.
2. Will give the awarding agency, the Comptroller General
of United States, and if appropriate, the State, through
any authorized representative, access to and the right to
examine all records, books, papers, or documents related
to the award; and will establish a proper accounting
system in accordance with generally accepted
accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from
using their positions for a purpose that constitutes or
presents the appearance of personal or organizational
conflict of interest, or personal gain.
4. Will initiate and^ complete the work within the
applicable time frame after receipt of approval of the
awarding agency.
5. Will comply with the Intergovernmental Personnel Act
of 1970 (42 U. S. C. ง4728-4763) relating to prescribed
standards for merit systems for programs funded under
one of the nineteen statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 C. F. R. 900, Subpart F).
6. Will comply with all Federal statutes relating to
nondiscrimination These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352)
which prohibits discrimination on the basis of race, color
or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 U. S. C. ง1681-
1683, and 1685-1686), which prohibits discrimination
on the basis of sex; (c) Section 504 of the Rehabilitation
7.
Act of 1973, as amended (29 U. S. C. ง794), which
prohibits discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 U. S. C.
ง6101-6107), which prohibits discrimination on the
basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P. L. 92-255), as amended, relating to
nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616), as amended, relating to nondiscrimination
on the basis of alcohol abuse or alcoholism; (g) งง523 and
527 of the Public Health Service Act of 1912 (42 U.S.C.
290 dd-3 and 290 ee-3), as amended, relating to
confidentiality of alcohol and drug abuse patient records;
(h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C.
ง3601 et seq.), as amended, relating to nondiscrimination
in the sale, rental or financing of housing; (i) any other
nondiscrimination provisions in the specific statute(s)
under which application for Federal assistance is being
made; and (j) the requirements of any other
nondiscrimination statute(s) which may apply to the
application.
Will comply, or has already complied, with the
requirements of Titles II and III of the Uniform
Relocation Assistance and Real Property Acquisition
Policies Act of 1970 (P.L. 91-646) which provide for fair
and equitable treatment of persons displaced or whose
property is acquired as a result of Federal or federally
assisted programs. These requirements apply to all
interests in real property acquired for project purposes
regardless of Federal participation in purchases.
Will comply, as applicable, with provisions of the Hatch
Act (5 U.S.C. งง1501-1508 and 7324-7328) which limit
the political activities of employees whose principal
employment activities are funded in whole or in pan with
Federal funds.
Previous Edition Usable
Authorized for Local Reproduction
Standard Form 424B (Rev. 4/92)
Prescribed by OMB Circular A-102
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9. Will comply, as applicable, with the provisions of the
Davis-Bacon Act (40' U.S.C. งง276a" to 276a -"?), the
Copeiand Act (40 U.S.C. งง276c and 18 U. S. C.
งง874), and the Contract Work Hours 'and Safety
Standards Act (.40 U.S.C. ง'ง327-333), regarding labor
standards for federally assisted construction
subagreements.
10. Will comply, if applicable, with flood insurance
purchase requirements of Section 102(a) of the Rood
Disaster Protection Act of 1973 (P.L. 93-234) which
requires recipients in a special flood hazard area to
participate in the program and to purchase flood
insurance if the total cost of insurable construction and
acquisition is S 10.000 or more.
11. Will comply with environmental standards which
may be prescribed pursuant to the following: (a)
institution of environmental quality control
measures under the National Environmental Policy
Act of 1969 (P.L. 91-190) and Executive Order (EO)
11514; (b) notification of violating facilities pursuant
to EO 11738; (c) protection of wetlands pursuant to EO
11990: (d) evaluation of flood hazards in floodplains in
accordance with EO 11988; (e) assurance of project
consistency with the approved State management
program developed under the Coastal Zone
Management Act of 1972 (16 U.S.C. งง1451 et seq.);
(0 conformity of Federal actions to State (Clear Air)
Implementation Plans under Section 176(c) of the
Clear Air Act of 1955, as amended (42 U.S.C. งง 7401
et seq.); (g) protection of underground sources of
drinking water under the Safe Drinking Water Act of
1974, as amended, (P.L. 93-523); and (h) protection of
endangered species under the Endangered Species Act
of-1973, as amended, (RL. 93-205).
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12. Will comply with the Wild and Scenic Rivers Act of
1968 (16 U.S.C. งง1271 et seq.) related to protecting
components or potential components of the national
wild and scenic riyfirs systei|. ' ,; ^ ; ;::;; ;; : ;,,,,
13. Will assist the awarding agency in assuring compliance
with Section 106 of the National Historic Preservation
Act of 1966, as amended ฃ16 U.S.C. 470), EO 11593
(identification and protection of historic properties), an|
the Archaeological and Historic Preservation Act of 1974
(16U.S.C.469a-letseq.). '" :":" <"'
14. Will comply with RL. 93-348 regarding the projection oj
human subjects involved in research, development, and
related activities supported by this award of assistance,
15. Will comply with the Laboratory Animal Welfare Act of
. 1966 (RL. 89-544, as amended, 7 U.S.C. 2131 etseq.)
pertaining to the care, handling, and treatment of warm
blooded animals held for research, teaching, or Qther;
activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning
Prevention Act (42 U.S.C. งง 4801 et seq.) which
prohibits the use of lead based paint in construction of
rehabilitation of'residencespctures.
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17. Will cause to be performed the required financial and
compliance audits in accordance with the Single Audit
Act of 1984 or OMB Circular rfo, A-133, Audits qg
Institutions of Higher Learning and other Non-prqfiC
Institutions.
18. Will comply widi all applicable requirements of all other
Federal laws, executive orders, regulations and policies
governing this program.
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SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TITLE
APPLICANT ORGANIZATION
DATE SUBMITTED
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Standard Fonti 4248 (Rซซ, 4/W) tปa*k
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Project Narrative Statement
PROJECT NARRATIVE STATEMENT
Section 1 (Group Qualifications)
A. Group Eligibility
1. Do any of the following categories apply to your group? (yes/no) If the
answer is yes, check the categories below that apply and provide a detailed
explanation.
any members of your group potentially responsible parties (PRPs)?
_Was your group established by a PRP?
_Was/is your group sustained by a PRP?
_Was your group established by, or is it presently sustained by, any of the
following:
a corporation that is not incorporated for the specific purpose of repre-
senting affected individuals at the site?
an academic institution?
a political subdivision?
Does anyone in your group have financial involvement in a PRP (as other
than an employee or contractor)?
2. How many members are in your group? Is it made up of a coalition of
groups? (yes/no) If so, how many, and how did the groups come to-
gether? If not, how was your group formed?
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Project Narrative Statement
Section 1, cont.
B. Responsibility Requirements
1. Administrative and Management Capabilities: Please briefly describe the organi-
zational structure of your group in the space below. (Describe roles and responsibili-
ties of members, particularly members who will be responsible for financial manage-
ment of the grant and directing the activities of the contractor.)
2. Resources for Project Completion: What resources are available to your group to
help complete the TAG Project? (Include any plans that your group has for in-kind
contributions or for fund-raising and obtaining cash.)
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Project Narrative Statement
Section 1, cont.
3. Performance Record: Please describe your group's past performance with
satisfactorily completing projects and contract. (If your group has no past experi-
ence, EPA will evaluate the description, budget, and schedule you provide in
Section 2 of this application.)
4. Accounting and Auditing Procedures: What procedures does your group plan
to use for recordkeeping and financial accountability related to the grant? Please
identify the member of your group who will maintain your financial records.
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Project Narrative Statement
Section 1, cont.
5. Incorporation: Is your group incorporated specifically for the purpose of addressing
problems at this site? (yes/no) If not, what steps is your group taking to
incorporate for grant-related purposes?
6. Drug-Free Workplace Policy: Does your group promise not to engage in illegal
drug-related activities while carrying out activities using TAG funds? ; (yes/no)
C. Group Issues and Objectives
1. Health Considerations: How many group members have experienced health
effects from contamination at the site? Describe actual or potential health
threats the site poses to individual group members and the efforts members of your
group have undertaken to resolve or make known these health concerns.
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Project Narrative Statement
Section 1, cont.
2. Consolidation/Representation: Describe the number and diversity of affected
community organizations and individuals represented by your group, highlighting the
ways in which your group represents individuals affected by the site.
3. Tasks for Technical Advisors: Please describe how your group intends to use
your technical advisor to interpret technical Superfund information.
4. Information Sharing: How does your group intend to share information collected
with grant funds with the larger community?
-------
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Project Narrative Statement
Section 1, cont.
5. Economic/Environmental Considerations: How many group members have
experienced economic/environmental impacts from contamination at the site?
Please describe the actual or potential economic harm or loss of environmen-
tal amenities the site has imposed on individual group members, and efforts group
members have undertaken to resolve or make known these concerns.
Section 2 - Statement of Work for the Technical Advisor
A. Statement of Work: Please identify the technical advisor(s)' tasks for each phase of
the Superfund process. For each of these phases, please note what the technical
advisor will do, the estimated amount of time needed to complete each task, and
specific documents, reports, or other tangible work products you expect the technical
advisor to produce.
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project Narrative smtemem
Section 2, cont.
B. Detailed Budget: Prepare a budget for the technical assistance project. Indicate
the tasks to be completed by the technical advisor, the estimated number of hours,
and the cost for each task (including travel costs). Use footnotes to explain as-
sumptions made in the budget (such as hourly rate of advisor or adjustments for
inflation). This budget should identify everything that you expect to purchase with
grant funds.
The budget should show the amount of the group's matching contribution sepa-
rately from federal funds. Note that the grant funds (usually 80 percent) plus group
contribution (usually 20 percent) must equal the total project costs; grant funds
cannot exceed 80 percent of project costs for any budget period. In your state-
ment, be sure that you differentiate cash expenditures from in-kind'contributions.
Also, include explanations of the assumptions made in calculating the value of in-
kind contributions.
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ฉEPA
EPA Project Control Number
United States Environmental Protection Agency
Washington, DC 20460
Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(ti\ Have not within a three year period preceding this proposal been convicted of or had a civil judgement
( } endeS^ aga nstthem Yfor commission of fraud or a criminal offense in connection wrth obta.n.ng
attempting to obtain, or performing a public (Federal, State, or local) transact.on or contract under a
pubHc transaction; violation of Federal or State antitrust statutes or cornmiss.or.ofembezzlement
theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal,
State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this
certification; and
(d) Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default.
I understand that a false statement on this certification may be grounds for rejection of this proposal or
termination of the award. In addition, under 18 USC Sec. 1001. a false statement may result in a fine of up
to $10,000 or imprisonment for up to 5 years, or both.
Typed Name 8<. Title of Authorized Representative
Signature of Authorized Representative Date
I I | am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
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Assistance Identification Number:.
CERTIFICATION DRUG FREE WORKPLACE ACT OF 1988
The recipient certifies that it will provide a drug-free workplace by:
(a) publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the recipient's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
(b) establishing a drug-free awareness program to inform employees about:
(1) the dangers of drug abuse in the workplace;
(2) the recipient's policy of maintaining a drug:free workplace;
(3) any available drug counseling, rehabilitation, and employee assistance programs; and
(4) the penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
(c) making it a requirement that each employee engaged in the performance of the project be given a copy
of the statement required by paragraph (a);
(d) notifying the employee in the statement required by paragraph (a) that, as a condition of employment
under the award, the employee will:
(1) abide by the terms, of the statement; and
(2) notify the employer of any criminal drug statute conviction for a violation occurring in the work-.
place no later than five days after such convictions;
(e) notifying the'Award Official within ten days after receiving notice under subparagraph (d) (2) from an
employee or otherwise receiving actual notice of such conviction;
(f) taking one of the following actions, with 30 days of receiving notice under subparagraph (d)(2), with
respect to any employee who is so convicted:
(1) taking appropriate personnel action against such an employee, up to and including termination; or
(2) requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency;
(g) making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
The recipient shall insert in the space provided below the site(s) for performance of
work done in connection with the specific award
Place of performance (street address, city, county, state, zip code)
Typed Name and Title of Authorized Representative
Signature of Authorized Representative Date
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, EPA Project Control Number
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS. GRANTS. LOANS. AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement.
t
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, or an employee of a Member of Congress in connection with this Federal contract,
grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard
Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award of
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification .is a prerequisite for making
or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.
Typed Name and Title of Authorized Representative
Signature of Authorized Representative Date
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