EPA-540-K-03-001
inical Assistance Grant
Program:
:ion Forms with
Instructions
SS*SEP»?UTT3
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Office of Emergency and EPA540-K-03-001
Remedial Response February 2003
(5204G) www.epa.gov/superfund/tools/tag
Table of Contents
Table of Contents 1
Introduction 2
TAG Application: Initial Steps 3
How To Use This Booklet 3
Completing the Letter of Intent 4
Completing the Project Narrative Statement 6
Section 1. Group Qualifications 6
Section 2. Information Sharing 16
Section 3. Technical Advisor Work Plan 18
Section 4. Project Budget 22
Completing the Application For Federal Assistance
(Standard Form 424) 24
Completing Standard Form 424B-Assurances 30
Certification Regarding Debarment, Suspension, and
Other Responsibility Matters (EPA Form 5700-49) 32
Preaward Compliance Review Report 34
Certification Regarding Lobbying 36
Blank Application Documents 39
U.S. Environmental Protection Agency
Region 5, Library (PL-12J)
-12U1
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Introduction
A Technical Assistance Grant (TAG) helps your community participate in
decisionmaking at eligible Superfund sites. TAG funds are available to pay for
independent technical advisors to help you understand information, plans, and
documents about the cleanup of the Superfund site affecting you and a range of
related issues, including redevelop and reuse, public health concerns, and relocation.
A portion of TAG funds also can be used to publish newsletters, obtain relevant
supplies and equipment, or hire a grant administrator.
This booklet provides everything you need to apply for a TAG for your group.
This application package has been updated to be consistent with the new rules for
the TAG program that took effect in October 2000.
The package provides simple, clear, step-by-step directions for preparing your
application and completing all the forms required and includes samples to show you
what to do in each section. The package also includes a complete set of blank forms,
so you can fill in the necessary information for your group.
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TAG Application: Initial Steps
Your group should take four important steps before you begin to fill out the Superfund Technical Assistance
Grant (TAG) application forms contained in this booklet:
Step 1 -- Contact your EPA Project Officer or Regional TAG Coordinator.
You should work closely with him or her throughout the process of applying for a TAG to get answers
for any questions that may arise. See page 55 for contact information.
Step 2 -- Make certain that your group is eligible to receive a TAG.
You should have already received two EPA fact sheets to help you. They are "Technical Assistance
Grants (TAG): Program Fact Sheet" and "Technical Assistance Grants (TAG): Applying for a TAG."
The "Applying for a TAG" fact sheet contains a number of questions about your group that should be
particularly helpful.
Step 3 - Find out if your state government must review your TAG application.
Some states require you to send them a copy of your TAG application for review so your Governor can
stay informed of all of the grants awarded within the state. State requirements regarding this "inter-
governmental review" vary. Ask your Regional TAG Coordinator (see page 55) whether your state requires
intergovernmental review. If so, ask the TAG Coordinator who to contact in your state to find out the proce-
dures to follow. You also can get this information at: www.whitehouse.gov/omb/grants/spoc.html.
IMPORTANT NOTE: EPA cannot process your application package without evidence that you have submitted
the application to the state reviewers, if required in your state. States have 60 days to complete the
intergovernmental review process.
Step 4 -- Notify your EPA regional office that you plan to apply for a TAG
Instructions for preparing your Letter of Intent and a helpful Sample are shown on pages 2 and 3.
| [how To Use This Booklet |
To simplify your work, this booklet contains step-by-step instructions for filling out each of the required
forms. A sample, using an imaginary group called the Woodtown Landfill Coalition, is included to show how
each completed form should look (shown in bold type in each section). Forms included are:
1. A multi-page "Project Narrative Statement," which includes the "budget" and "scope of workTwork plan"
specified in the new TAG rules plus information about your group and how you will manage a TAG.
2. Standard Form (SF) 424, "Application for Federal Assistance" (1 page).
3. SF 424A, "Budget Information - Non-Construction Programs" (2 pages).
4. SF 424B, "Assurances - Non-Construction Programs" (2 pages).
5. EPA Form 5700-49, "Certification Regarding Debarment, Suspension, and Other Responsibilities
Matters" (1 page).
6. EPA Form 4700-4, "Preaward Compliance Review Report for Applicants Requesting Federal Financial
Assistance" (1 page).
7. "Certification Regarding Lobbying" (1 page).
You can find blank copies of the all of the forms beginning on page 39. Before filling out any of them, it may
be useful to photocopy the blanks and use the copies to create a draft application package. When you are
comfortable with all your entries, you can transfer the information to the blank forms for submission to EPA.
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Completing the Letter of Intent
NOTE: Applicable sections of 40 CFR Part 35, Subpart M, the regulations for the Technical Assistance Grant
Program, are cited as needed throughout this section.
Your group must send a LETTER OF INTENT to your EPA regional office stating that you
intend to file a TAG application [see 40 CFR 35.4105, 4106, AND 4110].
Your Letter of Intent should include the following information:
• Name of group;
• Contact person with address and daytime telephone number; and
• Name of the site for which you are seeking a TAG.
A sample Letter of Intent for an imaginary group is on the next page and shows what to say in your
letter.
To find the address of your EPA regional office, see page 55.
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Woodtown Landfill Coalition
Main Street
Woodtown, CT 06898
September 16, 2001
TAG Project Officer
Superfund Management
EPA Region 1
Mail Code: HPC-CAN7
John F. Kennedy Federal Building
Boston, MA 02203
Dear Sir/Madam:
We intend to apply for a Technical Assistance Grant. The Woodtown Landfill Coalition is composed of the
Woodtown Citizens Task Force and the Smithtown Outing Club. We plan to use any awarded grant funds to obtain
assistance in interpreting technical information generated during the Superfund cleanup process at the Woodtown
Landfill site in Litchfield County, Connecticut. Please send an application and other relevant materials to me at the
address listed above. The group hopes to file its application in January 2002.
Sincerely,
Pat Jones, Executive Director
Woodtown Landfill Coalition
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Completing the Project Narrative Statement
NOTE: Applicable sections of 40 CFR Part 35, SubpartM, the regulations for the Technical Assistance Grant
Program, are cited as needed throughout this section.
The Project Narrative Statement consists of a budget and a work plan, or scope of work [40
CFR 35.4011 through 35.4055]. It is an essential part of the TAG application. In the State-
ment, you also describe your group and how you will responsibly manage funds provided
through the TAG
The form for the Project Narrative Statement follows a question and answer format that is, for the most part,
self-explanatory. To show you the type of information EPA is looking for, a sample Statement has been
prepared for an imaginary group called the Woodtown Landfill Coalition.
The sample begins on the next page, and the answers for the imaginary group are shown in bold type. Refer
to it as often as needed as you prepare your group's Project Narrative Statement.
Section 1. GROUP QUALIFICATIONS - The information in this section tells EPA
about your group and its eligibility for a TAG .
A.1. and 2. Support from Other Groups -- Qestions 1 and 2 in this section help EPA determine whether
your group has members or support from organizations that are not eligible to receive TAGs. If you do not
have a complete list of PRPs for your site, contact the Remedial Project Manager (RPM) or Community
Involvement Coordinator (CIC) for the site. Answer "Yes" or "No" to each question by placing a "X" in the
appropriate box.
A.3. and 4. Group Background - Questions 3 and 4 in this section provide background on the size of
your group and how it was formed, in order to help EPA determine if your group meets the requirements to
be a TAG recipient. Answer "Yes" or "No" to each question by placing a "X" in the appropriate box, and
provide a detailed explanation for any "Yes" answers.
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Project Narrative Statement
Section 1. Group Qualifications
A. Group Eligibility
1. The first five items in this section concern your group's relationship, if any, with those who have been
identified as potentially responsible parties (PRPs) at the site. If you do not have a complete list of PRPs for
your site, contact the Remedial Project Manager (RPM) or Community Involvement Coordinator (CIC) for the
site. Provide a detailed explanation for any "Yes" answers.
Yes No
| | ["x"! Are any members of your group potentially responsible parties (PRPs)?
| | Qf] Was your group established by or does it represent a PRP?
| | ["x~| Does anyone in your group have financial involvement in a PRP (other than as an
employee or contractor?)Is your group presently sustained by a PRP?
| | | x | Does your group presently receive money or services from a PRP?
2. [| [x] Was your group established, or is it sustained, by an "ineligible entity" [defined in 40 CFR 35.4105]
(check all that apply):
APRP?
A national organization?
An academic institution?
A political subdivision?
3. How many members are in your group? 105
4. | X | | | Is your group incorporated (or planning to incorporate) as a non-profit organization for the
specific purpose of representing affected individuals at the site?
OR
| X| | | Was your group previously incorporated for another purpose?
| X | | | If your group was previously incorporated for another purpose, does it
include all the individuals and groups who joined in applying for the TAG?
Explain how your group was formed and the history of your group's involvement at the site. If your group devel-
oped out of a coalition of other groups, also include the names of these groups and why they joined together?
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 1995, is the health effects resulting from
contamination at the site. The Smithtown Outing Club, founded in 1965, organizes a variety of
outdoor trips around Litchf ield County. The Club's main concern is the effects of contamination
from the Woodtown Landfill site on the surrounding environment. Since both groups require
technical assistance, they have chosen to form an incorporated coalition for the purpose of this
program.
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Completing the Project Narrative Statement (continued)
Section 1-GROUP QUALIFICATIONS (continued)
B.1. Administrative and Management Capabilities - As a TAG applicant, your group must demonstrate
its capability to adequately and responsibly manage a grant. In answer #1, you must demonstrate that your
group has established, or has plans to establish reliable procedures for managing a TAG.
NOTE: Although the last sentence of the Sample anwer refers to "attached bylaws," no bylaws for the
imaginary Woodtown Landfill Coalition have been included. BE SURE TO ATTACH YOUR GROUP'S
BYLAWS TO YOUR TAG APPLICATION.
B.2. Resources for Project Completion -- Describe the resources available to your group and include
plans your group has for providing "in-kind" goods and services or money that will be contributed towards its
matching share.
Your matching share can include the following "in-kind" services and supplies, as long as you document
them in your file.
Volunteered services, such as:
• A bookkeeper's work keeping your group's financial records and preparing required financial reports.
• A lawyer's aid in drafting a contract for your technical advisor.
• Your project manager's oversight of contracts.
• A group member's efforts to produce a group newsletter.
• The time spent by group representatives (such as board members) attending site related
meetings.
Donated supplies, such as:
• Use of equipment (such as a computer or copier) and office space.
• Office supplies (such as paper and pencils).
• Photocopying, printing, and postage.
• Telephone calls.
• Meeting space.
• Other costs in your TAG application that are approved by EPA.
"In kind" contributions must be included in your approved budget. The value of equipment, such as
a calculator or computer donated to the project, is based on fair-market value for purchase or rental of the
item. However, only that portion of the property's use that you can directly attribute to the TAG project
counts as an in-kind contribution. The value of donated office space or space for meetings 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.
The value of services donated to the project is based on the price you would pay for similar work in your
organization or your geographical area.
Your records should show how you calculated the value of all "in-kind" contributions included in your budget.
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Section 1. Group Qualifications (continued)
B. Responsibility Requirements
1. Administrative and Management Capabilities
In the space below, please describe the organizational structure of your group and the roles and responsibili-
ties 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 Smithtown Outing Club have operated as nonprofit
organizations for at least five years and have existing administrative structures that oversee and
guide their activities. The Woodtown Landfill Coalition is also recognized by the State of Con-
necticut as a nonprofit corporation, 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 Execu-
tive Director will be the group's designated representative for the purpose of signing all docu-
ments related to the TAG. 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 additional 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 at this time, we will require the services of a technical
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 $12,500-20 percent of the total project cost-with a combination of in-kind volunteer
services and cash contributions. The cash portion will come from annual dues and fund raising
activities. We also have received about $500 in donations in each of those years. In-kind contribu-
tions will come from donated meeting space, planning activities, time spent managing the techni-
cal advisor, accounting 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 freelance writer and a local newspaper editor will design, write, and edit a
newsletter devoted solely to the site and technical assistance project. Attachment 1.B. provides a
detailed budget, including a breakdown of federal and matching shares.
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Completing the Project Narrative Statement (continued)
Section 1-GROUP QUALIFICATIONS (continued)
B.3. Performance Record - Describe other projects and contracts your group has managed, including
whether they were completed successfully.
If your group has no past experience in completing previous projects and contracts, EPA will evaluate your
application based on the description, budget, and schedule you provide in Section 2 of the application.
NOTE: In the sample on the next page, the imaginary Woodtown Landfill Coalition provides their
"Technical Advisor Work Plan" (Attachment A) and "Proposed Schedule and Costs for a Technical
Advisor" (Attachment B) for EPA's use in evaluating its ability to manage the project, since they have
no past performance details.
B.4. Accounting and Auditing Procedures - Describe how your group plans to keep records and the
accounting procedures it will use to manage TAG funds. Identify the member of your group who will maintain
your financial records.
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Section 1. Group Qualifications (continued)
B. Responsibility Requirements (continued)
3. Performance Record
Please describe your group's past performance in 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
carried out fund-raising and community events that entailed organizing and budgeting activities.
The "Technical Advisor Work Plan" (Attachment 1) included in this application describes in detail
our proposed plan for use of a technical advisor's services.
Attachment 2, "Proposed Schedule and Costs for a 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 general ledger for the sole manage-
ment of the TAG The two treasurers on the Executive 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 same 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 Woodtown 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 financial reports required by EPA and the state.
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Completing the Project Narrative Statement (continued)
Section 1-GROUP QUALIFICATIONS (continued)
B.5. Incorporation - If your group is informed that it has been chosen to receive a TAG, you must affirm
that your group has filed the necessary papers for incorporation with the state.
Remember, you must submit documentation to EPA (a letter from your state) that your group has
been officially incorporated by the state by the time you make your first request for payment.
For additional information, see the "Technical Assistance Grants (TAG): Incorporation and Tax-Exempt
Status" fact sheet.
B.6. Certifications - You must sign the three important statements listed below to comply with federal
regulations [40 CFR 35.4125].
• Certification Regarding Debarment, Suspension, and Other Responsibility Matters
(EPA Form 5700-49)
• "Preaward Compliance Review Report for Applicants Requesting Federal Financial Assistance" (Form
4700-4)
• Certification Regarding Lobbying
See pages 30-37 for sample and instructions for completing these certifications.
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Section 1. Group Qualifications (continued)
B. Responsibility Requirements (continued)
5. Incorporation
Is your group incorporated specifically for the purpose of addressing problems at this site? (Answer "yes" or
"no") yes
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 Coali-
tion and general group goals.
6. Certifications
Attach copies of the completed "Certification Regarding Debarment, Suspension, and Other Responsibility
Matters" (EPA Form 5700-49), "Preaward Compliance Review Report for Applicants Requesting Federal
Financial Assistance" (Form 4700-4), and "Certification Regarding Lobbying" to this Project Narrative
Statement.
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Completing the Project Narrative Statement (continued)
Section 1-GROUP QUALIFICATIONS (continued)
C.1. Number of Members of Your Group Affected by the Site
C.2. Health, Economic, and Environmental Effects - Describe how the health, economic condition,
and environmental well-being of your group members and the citizens they represent are or have been
affected by the contamination at the site. (See Sample on the next page.)
C.3. Consolidation/Representation -- Describe the number and diversity of community organizations and
individuals represented by your group. Highlight the ways your group represents individuals affected by the
site. (See the Sample on the next page.)
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Section 1. Group Qualifications (continued)
C. Group Issues and Objectives
1. How many members of your group are affected by the site? 105
2. Health, Economic, and Environmental Effects
Describe the ways in which group members and those they represent are affected by contamination at the
site, including actual or potential health threats posed to and economic and environmental effects felt by
them.
Concern about contaminated private wells and possible health effects resulting from contamina-
tion at the site led to the formation of the Task Force. As explained in a private sampling report,
residents' well water continues to be undrinkable due to its strong odor, brownish color, and
unpleasant taste, which the 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 gotten
mysterious skin rashes after bathing in well water and are concerned about their health. As a
result, community members have been forced to use bottled water for nearly four years. EPA is
considering members' requests for an alternate water supply after the Agency has completed its
sampling at the site. The Woodtown Citizen Task Force, as a member of the Woodtown Coalition,
wants to ensure that all potential health risks related to the site are investigated thoroughly and
that the remedial action selected will restore the quality of community well water supplies.
Members of the Smithtown Outing Club (one of the Coalition member-organizations) have, since
the Club's inception in 1975, actively organized a variety of swimming, canoeing, fishing, and
hiking trips within Connecticut. Many of the 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. For this reason, many club members have feared swimming or canoeing in the
river. Additionally, fishing in the river has been banned. The Smithtown Outing Club wants the site
so that the landfill no longer pollutes the Rolling River.
Members of the Woodtown Landfill Coalition face a number of economic concerns related to
contamination of the Woodtown Landfill site. The main worry is that publicity about contamination
from the landfill may cause the property values of homes with contaminated water or with
riverfront exposure to the Rolling River to decrease significantly. 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 area. Coalition mem-
bers also have experienced significant financial burdens from not being able to use well water.
For example, members must purchase bottled water for drinking and cooking and cannot wash
laundry in residential washing machines, because the contaminated water stains their clothes.
3. 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.
The Woodtown Landfill Coalition membership represents most people affected by and concerned
about the Woodtown Landfill site. For example, the members of the Woodtown Citizen Task Force
include representatives of individual residents, community groups, and neighborhood businesses
near the Woodtown Landfill site. The Smithtown Outing Club's members include people who
regularly use Litchfield County's river and woods for recreation and are concerned about possible
environmental damage from the Landfill. Over 75 percent of the Coalition's members live within a
one-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 1995.
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Completing the Project Narrative Statement (continued)
NOTE: Applicable sections of 40 CFR Part 35, Subpart M, the regulations for the Technical Assistance Grant
Program, are cited as needed throughout this section.
Section 2. INFORMATION SHARING - This section tells EPA about how your
group will share technical and other information collected through the TAG project
with the overall community [40 CFR 35.4135(3)].
A. Describe the specific steps your group will take to share information collected in your TAG project with
the rest of the community. (See the Sample on the next page.)
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Section 2 (Information Sharing)
1. How does your group intend to share information collected using 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 information generated by the
technical advisor. 320 copies of this newsletter will be printed for each issue. 200 of these copies
will be distributed by hand to a list of community residents, and 120 copies will be mailed directly
to Coalition members and the local press. In addition, all final documents produced by the techni-
cal advisor will be sent to EPA to be placed in the Information Repository established for the site
at the Woodtown Public Library, which is accessible to everyone in the community. To encourage
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 advertise the meeting by putting an ad in the local newspaper.
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Completing the Project Narrative Statement (continued)
NOTE: Applicable sections of 40 CFR Part 35, Subpart M, the regulations for the Technical Assistance Grant
Program, are cited as needed throughout this section.
Section 3. TECHNICAL ADVISOR WORK PLAN - This section explains your group's
plan for using TAG funds to work with your Technical Advisor to participate in each
stage in the Superfund cleanup process at your site [40 CFR 35.4140(2), (3), and (4)].
To prepare for writing the Technical Advisor Work Plan, talk to the Remedial Project Manager (RPM) and
Community Involvement Coordinator (CIC) for your site to find out when specific technical milestones are
expected to be reached and the schedule for other important activities at the site. Review the TAG program
fact sheets on "Applying for a TAG," "Managing Your TAG," and "Finding, Choosing, and Hiring a Technical
Advisor."
NOTE: The Technical Advisor Work Plan and detailed Project Budget you prepare in this section should describe
the work you plan to do, over a number of years if necessary, to participate in the Superfund process at your site.
A. Technical Advisor Work Plan - The information in this section explains how your group plans to use
personnel for management/coordination and technical advice.
For example, your Technical Advisor Work Plan must explain:
• The list of tasks you want your technical advisor to perform, such as review of the Remedial Investiga
tion Report;
• The estimated amount of time your technical advisor will need to complete each of the specified tasks;
• The products (for example, memoranda, fact sheets, or reports) you expect the advisor to provide; and
• How your technical advisor will work with your board of directors and project manager.
In general, technical advisor activities that are eligible for funding under a TAG include:
• Reviewing and interpreting site-related documents;
• Participating in site visits to gain a better understanding of site activities;
• Traveling to meetings and hearings directly related to the situation at the site;
• Meeting with your group to explain technical information;
• Helping your group communicate site-related concerns to EPA;
• Communicating technical information to the community; and
• Participating in health and safety training.
Since your Technical Advisor Work Plan may require more room than the form allows, you may provide the
Work Plan as an attachment to the application. (See Sample Attachments 1 and 2 on the following pages
for examples of how to format your Technical Advisor Work Plan and to display the schedule and anticipated
costs of technical advisor activities. The formats shown are suggestions only. You may develop different
formats, if you wish.)
Be sure to include a reference to the Attachments in the application.
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Attachment 1
Statement of Work
This section provides a detailed description of individual technical advisor tasks and their purposes.
Technical assistance tasks described in this statement of work are based on conversations with the
EPA Regional staff (the Remedial Project Manager (RPM) and the Community Involvement Coordinator
(CIC) for the site).
For all reports and reviews completed by the technical advisor, 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 so it can 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 Rl 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 contamination from the Woodtown Landfill site into the Rolling River. The advisor
will be expected to participate in a proposed meeting between EPA staff and residents scheduled
for the start of the Rl. Upon completion of the Rl report, the advisor will be expected to help the
Coalition evaluate the results. Another key document to be reviewed 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 proposed 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 Coalitions'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 public 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 assessment thoroughly to ensure that public
health is being adequately considered. The advisor will prepare a summary report on the potential
health risks posed by the site and 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)
The technical advisor will be expected to carry out oversight functions during this stage. The
advisor will review the final design to ensure that the design is consistent with the ROD. The
advisor will be expected to report his/her findings in memorandum 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)
During the remedial action phase, the advisor will be expected 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.
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Review
Schedule/Tasks
Attachment 2
PROPOSED SCHEDULE OF TASKS AND COSTS FOR TECHNICAL ADVISOR
Prepare
YEAR 1 Remedial Investigation (Rl)
• Review work plan
• Issue evaluation memo
• Attend Rl kickoff 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
YEAR 2 Feasibility Study (FS) Continued
• Brief Coalition on FS and attend FS meetings
• Review Coalition comments on FS
• Review ROD and prepare summary memo
YEARS 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
Travel (site visits and attendance at Woodtown Coalition Meetings and Public Hearings)
• Mileage ($0.34 per mile) $500
• Lodging and Meals ($100 per diem) $400
Total Travel Costs
view
X
X
X
X
X
X
X
X
X
Memo/ Attend
Report Meeting
X X
X
X X
X X
X X
X X
X
X
X X
X X
X X
Total
#of
Hours
30
25
8
52
45
85
60
80
15
60
100
75
Cost
$/hour
$2,280
$1,900
$608
$3,952
$3,420
$6,460
$4,560
$6,080
$1,140
$4,560
$7,600
$5,700
Cost of Advisor
Total Cos
of Advise
$12,160
$11,020
$11,780
$7,600
$5,700
$48,260
Administrative Costs
• Telephone
• Postage
• Copying
Total*
$500
$200
$140
Total Administrative Costs
$900
160
145
155
100
75
635
$840
Total (federal share)$50,000
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Completing the Project Narrative Statement (continued)
Section 4. PROJECT BUDGET - This section summarizes costs by type of activity and
indicates whether these funds will come from your TAG (federal) or the group's matching
contribution [40 CFR 35.4130].
A. Detailed Budget -- In this section, describe all the costs involved in your TAG project. (See Sample
Attachment 3. The format shown is only a suggestion. You may develop a different format, if you wish.)
Attachment 3, on the next page, summarizes costs by type of activity and indicates whether these funds
will come from your TAG (federal) or the group's matching contribution. Your detailed Project Budget
should include everything you think will cost money throughout the life of the project, because adding
items to the budget later requires written approval from EPA.
22
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Attachment 3
Project Budget for Three-Year Budget Period
1. Federal Share:
Cost
• Labor (Technical Advisor, and may include Administrator)
635 hours at $76.00 per hour $48,260 $48,260
• Travel $900 $900
• Other Costs
Telephone $500
Postage $200
Copying, FAX, Printing $140 $840
Total $50,000
2. Matching Share:
• Incorporation $240
• Newsletter (writing, editing, distribution)
$2,300
• Meeting Space $900
($50 per meeting, 6 meetings per year, or 50x6x3 years)
• Accounting, bookkeeping
$1,560
(1 hour per week for 3 years at $10 per hour)
• Meetings of the Board of Directors
(5 members, 20 meetings, 3 hours each,
$25 per hour per member) $7,500
Total $12,500
Total Project $62,500
23
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Completing the Application For Federal Assistance
(Standard Form 424)
Following are instructions for filling out each numbered item in Standard Form (SF) 424.
This form is used to provide general information about your TAG group. It certifies that you
have determined your state's intergovernmental review requirements and requires the
signature of an authorized representative of your group.
1. Type of Submission - Check "non-
construction"
2. Date Submitted -- Type in current date
Applicant Identifier - Leave blank
3. Date Received by State - Leave blank
State Application Identifier - Leave blank
4. Date Received by Federal Agency -
Leave blank
Federal Identifier - Leave blank
5. Applicant Information -- Type in your
group's name. Place "N/A"in the "Organi-
zational Unit" box because this is not
applicable to TAG applicants. Type in your
group's address. Type in the name and
telephone number of the person who
would be able to supply additional informa-
tion if needed.
6. Employer Identification Number (EIN) -
Type in your group's EIN. If you do not
have an EIN, call the U.S. Internal Rev-
enue Service number in the "Government
Listings" of your local telephone directory.
Ask for IRS Form SS-4 ("Application for
Employer Identification Number"). Fill it out
and follow directions in the "How to Apply"
section on the Form to submit it by mail, by
telephone, or by fax.
7. Type of Applicant - Type "N" in the box
and type "Non-profit citizen organization" at
the end of the list of choices, next to "N.
Other (Specify/'.
8. Type of Application -- Check "New" or, if
you already have a TAG check "continua-
tion."
NOTE: Leave blocks 9& Was is.
11. Title of Project - Type in the name of the
Superfund site where the TAG will be used
under 'Technical assistance for."
12. Areas Affected by Project - List the
municipalities, towns, counties, and states
adjacent to, encompassing, and affected
by the site.
13. Proposed Project Start Date/End Date -
Ask your EPA Regional Office when
funding is likely to be approved if you
receive an award. Type in this date or the
date you wish to begin receiving funds,
whichever is later.
14. Congressional Districts - In block "a.,"
type in the Congressional district number
and state abbreviation for the area where
the offices of your incorporated group is
located. In block "b.," type in the Congres-
sional district number and state abbrevia-
tion for the area that encompasses the
site. If you do not know the district num-
bers, ask your local library.
15. Estimated Funding - Type in the amount
of money your are asking EPA to provide
(block "a"), the amount of "matching"
funds you will provide (block "b"), and the
total (block "g"). Copy these numbers from
your Project Narrative Statement. The
amount in block "a" must not be more than
$50.000 and not more than 80% of the
total in block "g".
16. Intergovernmental Review -- Type in the
date that your TAG application was made
available to your state's intergovernmental
review 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 - Type in the
information requested in "a."-"c." Your
group's project manager must sign and date
("d. "and "e.") the application.
24
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APPLICATION FOR
OMB Approval No. 0348-0043
FEDERAL ASSISTANCE
1. TYPE OF SUBMISSION:
S" plication
Construction
|Xj Non-Construction
Preapplication
L~3 Construction
!~] Non-Construction
5. APPLICANT INFORMATION
2. DATE SUBMITTED Applicant Identifier
December 28, 2001
3. DATE RECEIVED BY STATE State Application Identifier
4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier
Legal Name:
Woodtown Landfill Coalition
Address (give city, county, State, and zip code):
Main Street
Woodtown, CT 06898
Litchfield Countv
6. EMPLOYER IDENTIFICATION NUMBER (EIN):
Qj3~r>lxjlx
xl xl xl
8. TYPE OF APPLICATION:
L>] New D Continuation D Revision
If Revision, enter appropriate letter(s) in box(es) I I I
A. Increase Award B. Decrease Award C. Increase Duration
D. Decrease Duration Other(spec/'/x):
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
el 6 — 8 o |e
TITLE: Superfund Technical Assistance Grant
12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):
Smithtown, Woodtown, Litchfield, CT
13. PROPOSED PROJECT
Start Date Ending Date
11/1/01 11/1/04
Organizational Unit:
NA
Name and telephone number of person to be contacted on matters involvin;
this application (give area code)
Pat Jones (203) ###-####
7. TYPE OF APPLICANT: (enter appropriate letter in box)
H
A. State H. Independent School Dist.
B. County . State Controlled Institution of Higher Learning
C. Municipal J. Private University
D. Township K. Indian Tribe
E. Interstate L. Individual
F. Intermunicipal M. Profit Organization
G. Special District N. other (Specify) Nonprofit Citizen
Organization
9. NAME OF FEDERAL AGENCY:
U.S. Environmental Protection Agency
11. DESCRIPTIVE TITLE OF APPLICANTS PROJECT:
Technical Assistance at the
Woodtown Landfill Site
14. CONGRESSIONAL DISTRICTS OF:
a. Applicant
6(CT)
15. ESTIMATED FUNDING:
a. Federal
b. Applicant
c. State
d. Local
e. Other
f. Program Income
g. TOTAL
$ 50,000
$ 12,500
$
$
00
00
$ .°°
$
00
$ 62,500
b. Project
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE
ORDER 12372 PROCESS?
a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:
DATE 9/1/01
b. No. D PROGRAM IS NOT COVERED BY E. O. 12372
D OR PROGRAM HAS NOT BEEN SELECTED BY STATE
FOR REVIEW
17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
O Yes If "Yes," attach an explanation. Q NO
18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE
DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE
ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED.
a. Type Name of Authorized Representative
Pat Jones
d. Signature of Authorized Representative
P0t joiA.es
b. Title c. Telephone Number
Executive Director (203) ###-####
e. Date Signed December28, 2001
Previous Edition Usable
Authorized for Local Reproduction
Standard Form 424 (Rev. 7-97)
Prescribed by OMB Circular A-102
-------
Completing Standard Form 424A-Budget Information
I Section A—Budget Summary
1 .a. Grant Program, Function, or Activity - Type in the name of the Superfund site.
1.b. Catalog of Federal Domestic Assistance Number ~ Leave this block as is.
NOTE: Leave all other blocks in Row 1 blank. Also leave blocks "a" and "b" in Rows 2-5
as they apprear.
2.c-5.g - Type in "See Detailed Budget in Project Narrative Statement, Section 2.B." across
columns as shown on the Sample.
(Note: Budget information is requested in Project Narrative Statement.)
Section B—Budget Categories
6.a-7.k - Type in "See Detailed Budget in Project Narrative Statement, Section 2 .B." across
columns as shown on the Sample.
26
-------
BUDGET INFORMATION - Non-Construction Programs
OMB Approval No. 0348-0044
'* ' *' ' '•'? ^v-sjkili v|ft ; -'•" r ,, -
Grant Program
Function
or Activity
(a)
1 . Technical
Assistanre
2 Grant at:
Woodtown
Landfill Site
3.
4.
5. Totals
>t I & tf I$'*1S W ?
*k-S*,,.-/^,,,^vii< ,»,.- ..^. ,w,,,;, ,
Catalog of Federal
Domestic Assistance
Number
(b)
66.806
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)
Estimated Unobligated Funds
Federal
(c)
$
$
Non-Federal
(d)
$
New or Revised Budget
Federal
(e)
$
Non-Federal
(f)
$
Total
(g)
$
See detailed budget in Project Narrative Statement Section 2.B.
$
$
$
$
GRANT PROGRAM, FUNCTION OR ACTIVITY
(1) (2) (3) (4)
$
$
Total
(5)
$
See detailed budget in Project Narrative Statement Section 2.B.
$
$
$
$
- >,'^fe J^v:iX -*vV J'SStl^l^' '/ % &^ ^ I '* \ '"f^S.^^'l v^-^^W'Jl^ ,,:-.,«
7. Program Income
$
$
$
$
Authorized for Local Reproduction
Previous Edition Usable
Standard Form 424A (Rev. 7-97)
Prescribed by OMB Circular A-102
-------
Completing Standard Form 424A-Budget Information (continued)
Section C—Non-Federal Resources
8.a. Grant Program - Type in the name of the Superfund site.
8.b.-8e. and 9-12 - Type in "See Detailed Budget in Project Narrative Statement, Section 2.B."
across columns as shown on the Sample.
Section D—Forecasted Cash Needs
13. Federal - In the column labeled "Total for 1st Year", type in the total amount of money your are
asking EPA to provide for your project, as shown in the Sample on the next page. (Get this
amount from your Statement of Work or block 15.a. of the SF 424 "Application for Federal
Assistance" that you have already filled out.) Then, type in the portion of the estimated total that
you expect to need for each stated time period. The sum of the four quarterly amounts should be
equal to the total amount shown. (Don't spend a lot of time on this section—a rough estimate is
fine.)
14. Non-Federal - In the column labeled "Total for 1st Year", type in the total amount of "matching"
funds you will provide for your project, as shown in the Sample on the next page. (Get this
amount from your Statement of Work or block 15.b. of the SF 424 "Application for Federal
Assistance" that you have already filled out.) Then, type in the portion of the estimated total that
you expect to need for each stated time period. The sum of the four quarterly amounts should be
equal to the total amount shown.
15. Totals
Type in the total amount for each column of Flows 13 and 14, as shown in the Sample on the next
page.
| Section E—Budget Estimates of Federal Funds Needed for Balance of the Project
16.-20. -- Leave blank, as shown on the Sample on the next page.
Section F—Other Budget Information
21. and 22. ~ Type "N/A" in each block.
23. Remarks - Leave this block blank.
28
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MK^^Wf^Z^^f-'r;-*,-- \A-Js.'.l S*'>? ISfiCIIOIiC^ildiiiSfil^^ ,,;.j;^-*:-^^*
(a) Grant Program
Technical Assistance Grant at: Woodtown Landfill Site
8.
9.
10.
11.
1 2. TOTAL (sum of lines 8- 1 1)
&< f, HI
13. Federal
14. Non-Federal
1 5. TOTAL (sum of lines 13 and 14)
sl5xSMI-'!;II^Sp;^lSfSsc«^< 'W<*>fc«!^%:>.'*"«.* -,-"*% ;J|R& ^W-^t
i-i£IS^<:S||||f:l>^ll^^^i^y^'Sll
• ys Wt'Sy Jgjl A. jS
r
Total for 1st Year
$ 50,000
12,500
$ 62,500
(b) Applicant
(c) State
(d) Other Sources
(e) TOTALS
$ See detailed budget in Project Narrative Statement Section 2.B.
$
$
$
$
$
1st Quarter
$ 10,000
2,500
$ 12'500
2nd Quarter
$ 17,500
4,375
$ 21 ,875
3rd Quarter
$ 12,500
3,125
$ 15,625
4th Quarter
$ 10,000
2,500
$ 12,500
|||||ifi^^ : .. , ^ "f
(a) Grant Program
16.
17.
18.
19.
20. TOTAL (sum of lines 16-19)
21. Direct Charges: NA
FUTURE FUNDING PERIODS (Years)
(b) First
$
$
(c) Second
$
$
(d) Third
$
$
(e) Fourth
$
$
^4'"* J tr '- f" ^ ^£> •
22. Indirect Charges: NA
23. Remarks:
Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2
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Completing Standard Form 424B-Assurances
This form contains the regulations, policies, guidelines, and requirements which your group
must obey if you receive a TAG. Read it carefully. Then have your project manager or other
authorized representative (the person who is signing your SF 424 "Application for Federal
Assistance") sign it at the bottom, as shown in the Sample below and on the next page.
Be sure to submit the signed form with the rest of your application package.
Assurances—Non-Construction Programs
OMB Approval No 0348-0040
Public reportingburdenforthiscollectionof information is estimatedtoaverage 15 minutos par r«spons«, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and complying and reviewing the collection of Information 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 1 certify that the applicant:
I
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 costs)
to ensure proper planning, management and completion of the
project described in this application
2. Will give the awarding agency, the Comptroller General of
the 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 peisonal 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. §§ 4728-4763) relating to prescribed stan-
dards 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 Adminis-
tration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondis-
crimination. 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. §§ 1681-1683, 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. § 794), which prohibits discrimina-
tion on the basis of handicaps, (d) the Age Discrimination
Act of 1975, as amended (42 U S.C. §§ 6101-6107), which
prohibits discrimination on the basis of age; (e) the Drug
Abuse Office and Treatment Act of 1972 (P O 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 nondis-
crimination on the basis ofalcohol abuse or alcoholism.
(g) §§ 523 and 527 of the Public Health Service Act of 1912
(42 U.S.C. 290 dd-3 and 290 ce-3), as amended, relating to
confidentiality ofalcohol and drug abuse patient records,
(h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §
36701 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) un-
der which application for Federal assistance is being made;
and (j) the requirements of any other nondiscrimination
statute(s) which may apply to the application
7. Will comply, or has already complied, with the require-
ments 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 ac-
quired as a result of Federal or federally assisted piograms
These requirements apply to all interests in real propel ty
acquired for project purposes regardless of Federal partici-
pation in purchases.
8. Will comply, as applicable, with the provisions of the
Hatch Act (5 U.S.C. §§ 1501-1508 and 7324-7328) which
limit the political activities of employees whose principal
employment activities are funded in whole or in part with
Federal funds.
9 Will comply, as applicable, with the provisions of the
Davis-Bacon Act (40 U.S.C. §§ 276a and 276a-7), the
Copeland Act (40 U.S C. | 276c and 18U.SC S§ 874), and
the Contract Work Hours and Safety Standards Act (40
U S.C. §§ 327-333), regarding labor standards for feder-
ally assisted construction subagreements
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster Pro-
tection 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 insur-
ablc construction and acquisition is $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 Na-
tional 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; (e) evaluation of flood hazards in
flood plains in accordance with EO 11988; (e) assurance of
Previous Editions Usable
Page 1of2
Authorized for Local Reproduction
SF-424B (Rov 4/92)
Prescribed by OMB Circular A-102
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project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§ 1451 et seq.); (f) conformity of
Federal actions to State (Clear Air) Implementation Plans
under Section I76(c) of the Clear Air Act of 1955, as
amended (42 U.S.C. § 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 ol endangered species under the Endan-
gered Species Act of 1973, as amended, (P.L. 93-205).
12 Will comply with the Wild and Scenic Rivers Act of 1968
(16 U.S.C. §§ 1271 et seq.) related to protecting compo-
nents or potential components of the national wild and
scenic rivers system
13. Will assist the awarding agency in assuring compliance with
Section 106 ot 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 (16 U.S C 469a-l et seq.).
FfltjotA.es
14. Will comply with P.L. 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 the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S C. 2131 et .seq.)
pertaining to [he care, handling, and treatment of warm
blooded animals held for icsearch, teaching, or other
activities supported by this award of assistance
16. Will comply with the Lead-Based Paint Poisoning Preven-
tion Act (42 U S.C. §§ 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.
Executive Director
Signature ol Authorized Certifying Official
Woodtown Landfill Coalition
Applicant organization
Title
December 28, 2001
Previous Editions Usable
Page 2 of 2
Authorized lor Local Reproduction
SF-424B (Rev. 4/92)
Prescribed by OMB Circular A-102
31
-------
Certification Regarding Debarment, Suspension, and Other
Responsibility Matters (EPA Form 5700-49)
Your authorized representative MUST SIGN this form.
On the first blank line, TYPE in your group's name and the name and title of your group's autho-
rized representative as they appear on your SF 424 "Application for Federal Assistance" in sections
5. and 18.a.
Your group's project manager must sign the second blank line and type in the date.
If you cannot sign this certification, place a "X" in the box at the bottom of the page and attach a
statement explaining why you cannot.
32
-------
f/EPA
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 the principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily ex-
cluded from coverage by any 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, attempt-
ing to obtain, or performing a public (federal, state, or local) transaction or contract under a public transac-
tion: violation of federal, 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 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 transac-
tions (federal, state, or local) terminated or cause or default.
I understand that a false statement on this certification may be ground for rejection of this proposal or
termination of the award. In addition, under 18 DSC Sec. 1001, a false statement may result in a fine up to
$10,000 or imprisonment for up to 5 years, or both.
Pat Jones, Executive Director
Typed Name & Title of Authorized Representative
Pctt
Signature of Authorized Representative Date
I am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
-------
Preaward Compliance Review Report
Following are instructions for filling out EPA Form 4700-4, Preaward Compliance Review
Report for All Applicants Requesting Federal Financial Assistance. COMPLETE ALL SECTIONS
of the form, have your authorized representative SIGN IT, and SUBMIT the form with your
group's TAG application.
Recipients of federal financial assistance from
the U.S. Environmental Protection Agency must
comply with Title VI of the Civil Rights Acts of
1964, Section 13 of the 1972 Amendments to
the Federal Water Pollution Control Act,
Section 504 of The Rehabilitation Act of 1973,
The Age Discrimination Act of 1975, and Title IX
of the Education Amendments of 1972. The
information on this form is required to enable
the U.S. Environmental Protection Agency to
determine whether applicants and prospective
recipients are developing projects, programs
and activities on a nondiscriminatory basis as
required by these statutes.
If any item is not relevant to the project for
which assistance is requested, write "NA" for
"Not Applicable."
IA. "Applicant" means any entity that files an
application or unsolicited proposal or
otherwise requests EPA assistance.
IB. "Recipient" means any entity, other than
applicant, which will actually receive EPA
assistance.
1C. The EPA Project Number can be obtained
by contacting the Remedial Project Man-
ager (RPM) or Community Involvement
Coordinator (CIC) for the site.
II. Self-explanatory.
III. "Civil rights lawsuits" means any lawsuit
or complaint alleging discrimination on the
basis of race, color, national origin, sex,
age, or handicap pending against the
applicant and/or entity that benefits from
the grant. For example, if a city is the
named applicant but the grant will actually
benefit the Department of Sewage, civil
rights lawsuits involving both the city and
the Department of Sewage should be listed.
IV. "Civil rights compliance review" means
any review assessing the applicant's and/or
recipient's compliance with laws prohibiting
discrimination on the basis of race, color,
national origin, sex, age, or handicap. The
review should be listed If any part of it
covered the entity.
V. Self-explanatory.
VI. The word "community" refers to the area
under the applicant's and/or recipient's
jurisdiction. The "community" might be a
university or laboratory campus, or a commu-
nity within a large city. If there is significant
disparity between minority and nonminority
populations to receive service, which is not
satisfactorily explained, the Regional office
may require a map that indicates the minority
and nonminority population served by this
project, program or activity.
VII. "Population Characteristics" information is
required so that reviewers may determine if a
disparity in the proposed provision of services
will exist in the event the application is
approved for funding. Give population of
recipient's jurisdiction, broken out by catego-
ries as specified. In the event the applicant
cannot provide the requested information
because the funds will be distributed over a
wide demographic area, which is yet to be
determined, an explanation may be provided
on a separate sheet. For example, a state
applying for a capitalization grant under the
State Revolving Fund program may not know
which cities and counties will apply for, and
receive, SRF loans.
VIII.Self-explanatory.
IX. "Jurisdiction" means the geographical area
over which applicant has the authority to
provide service.
X. Self-explanatory.
34
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6ER&
Washington, DC 20460
Preaward Compliance Review Report for
All Applicants Requesting Federal Financial Assistance
FORM Approved
OMB No. 2090-0014
Expires 4-30-99
Note: Read instructions before completing form.
I. A. Applicant (Name, City, State)
Woodtown Landfill Coalition
Main Street
Woodtown, CT
B. Recipient (Name, City, State)
"NA"
C. EPA Project No.
CTDXXXXXXXX
II. Brief description of proposed project, program or activity.
To obtain assistance in interpreting technical information generated during the Superfund cleanup
process at the Woodtown Landfill site in Litchfield County, Connecticut.
III. Are any civil rights lawsuits or complaints pending against applicant and/or recipient? If
yes, list those complaints and the disposition of each complaint.
IV. Have any civil rights compliance reviews of the applicant and/or recipient been conducted
by any Federal agency during the two years prior to this application for activities which would
receive EPA assistance? If yes, list those compliance reviews and status of each review.
V. Is any other Federal financial assistance being applied for or is any other Federal financial
assistance being applied to any portion of this project, program or activity? If yes, list the other
Federal Agency(s), describe the associated work and the dollar amount of assistance.
U Yes Lj No
|_J Yes [3 No
|_| Yes £j No
VI. If entire community under the applicant's jurisdiction is not served under the existing facilities/services, or will not be
served under the proposed plan, give reasons why.
"NA"
VII. Population Characteristics
1. A. Population of Entire Service Area
B. Minority Population of Entire Service Area
2. A. Population Currently Being Served
B. Minority Population Currently Being Served
3. A. Population to be Served by Project, Program or Activity
B. Minority Population to be Served by Project, Program or Activity
4. A. Population to Remain Without Service
B. Minority Population to Remain Without Service
VII. Will all new facilities or alterations to existing facilities financed by these funds be
designed and constructed to be readily accessible to and usable by handicapped persons? If no,
explain how a regulatory exception (40 CFR 7.70) applies.
Number of People
320
30
320
30
320
30
0
0
|_| Yes LJ No
"NA"
IX. Give the schedule for future projects, programs or activities (or of future plans), by which services will be provided to all
beneficiaries within applicant's jurisdiction. If mere is no schedule, explain why.
Our plans call for producing six Issues of a newsletter containing information generated
by the technical advisor In order to keep the community members informed of Coalition
activities at the site, new Issues that arise, and proposals for addressing them throughout the cleanup.
X. I certify that the statements I have made on this form and all attachments thereto are true, accurate and complete. I
acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under
applicable law.
A. Signature of Authorized Official
pflt joi/tes
B. Title of Authorized Official
Executive Director
C. Date
December 28, 2001
For the U.S. Eavironnratal Protection Agency
PI Approved [""I Disapproved
Authorized EPA Official
Date
EPA Form 4700-4 (Rev. 1/90) Previous editions are obsolete.
35
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Certification Regarding Lobbying
Your authorized representatives MUST SIGN AND SUBMIT this certification with your group's
TAG application.
Contact the Remedial Project Manager (RPM) or Community Involvement Coordinator (CIC) for the site to
obtain the EPA Project Number.
36
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United States
Environmental Protection Agency
CTDXXXXXXXX
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 paid 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 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 foe
award documents for all sub-awards at all tiers (including sub-contracts, sub-grants,
and contracts under grants, loans, and cooperative agreements) and that all sub-
recipients 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 (he 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.
Pat Jones, Executive Director
Typed Name & Titleof Authorized Representative
'_ December 28, 2001
Signature o f Authorized Representative Date
37
-------
38
-------
Blank Application Documents
Following 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.
Documents you will find in this section include:
1. A multi-page "Project Narrative Statement," which includes the "budget" and "scope of workTwork plan"
specified in the new TAG rules plus information about your group and how you will manage a TAG.
2. Standard Form (SF) 424, "Application for Federal Assistance" (1 page)
3. SF 424A, "Budget Information - Non-Construction Programs" (2 pages)
4. SF 424B, "Assurances - Non-Construction Programs" (2 pages)
5. EPA Form 5700-49, "Certification Regarding Debarment, Suspension, and Other Responsibilities
Matters" (1 page)
6. EPA Form 4700-4, "Preaward Compliance Review Report for Applicants Requesting Federal Financial
Assistance" (1 page)
7. "Certification Regarding Lobbying" (1 page)
39
-------
Project Narrative Statement
Section 1. GROUP QUALIFICATIONS
A. Group Eligibility
1. The first four items in this section concern your group's relationship, if any, with those who have
been identified as potentially responsible parties (PRPs) at the site. If you do not have a complete list
of PRPs for your site, contact the Remedial Project Manager (RPM) or Community Involvement
Coordinator (CIC) for the site. Provide a detailed explanation for any "Yes" answers.
Yes No
Q Q Are any members of your group potentially responsible parties (PRPs)?
Q Q Was your group established by or does it represent a PRP?
Q Q Does anyone in your group have financial involvement in a PRP (other than as an
employee or contractor?)
Ql Q Is your group presently sustained by a PRP?
2. Q Q Was your group established, or is it sustained by, an "ineligible entity" [defined in
40 CFR 35.4105]? (check all that apply):
A PRP?
A national organization?
An academic institution?
A political subdivision?
3. How many members are in your group?
Q Q Is your group incorporated (or planning to incorporate) as a non-profit organization
for the specific purpose of representing affected individuals at the site?
OR
Q Q Was your group originally incorporated for another purpose?
Q Q If your group was originally incorporated for another purpose, does it
include all the individuals and groups who joined in applying for the TAG?
4. Explain how your group was formed and the history of your group's involvement at the site. If
your group developed out of a coalition of other groups, also include the names of these groups
and why the groups joined together? (Attach an additional sheet if needed.)
40
-------
Section 1. Group Qualifications (continued)
B. Responsibility Requirements
1. Administrative and Management Capabilities
In the space below, please describe the organizational structure of your group and the roles and
responsibilities of members, particularly members who will be responsible for financial
management 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.)
41
-------
Section 1. GROUP QUALIFICATIONS (continued)
B. Responsibility Requirements (continued)
3. Performance Record
Please describe your group's past performance in 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.)
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.
42
-------
Section 1. GROUP QUALIFICATIONS (continued)
B. Responsibility Requirements (continued)
5. Incorporation
Is your group incorporated specifically for the purpose of addressing problems at this site?
(Answer "yes" or "no")
If not, what steps is your group taking to incorporate for grant-related purposes?
6. Certifications
Attach copies of the completed "Certification Regarding Debarment, Suspension, and Other
Responsibility Matters" (EPA Form 5700-49), "Preaward Compliance Review Report for
Applicants Requesting Federal Financial Assistance," and "Certification Regarding Lobbying" to
this Project Narrative Statement.
43
-------
Section 1. GROUP QUALIFICATIONS (continued)
C. Group Issues and Objectives
1. How many members of your group are affected by the site?
2. Health, Economic, and Environmental Effects
Describe the ways in which group members and those they represent are affected by
contamination at the site, including actual or potential health threats posed to and
economic and environmental effects felt by them.
3. 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.
44
-------
Project Narrative Statement
Section 2. INFORMATION SHARING
A How does your group intend to share information collected with grant funds
with the larger community?
45
-------
Project Narrative Statement
Section 3. TECHNICAL ADVISOR WORK PLAN
A. Provide a succinct explanation of the tasks you wish your technical advisor to perform at
each stage of the cleanup process; how much of the technical advisor's time will be
necessary to complete the specified tasks at each phase of the cleanup process; and the
products you expect the technical advisor to provide.
46
-------
APPLICATION FOR
UIVID MppIOVai INO. UO<«J-UU
-------
BUDGET INFORMATION - Non-Construction Programs
OMB Approval No. 0348-0044
.S*^Ci--i™;'\5 ;*»', *\r. - i
Grant Program
Function
or Activity
(a)
1.
2.
3.
4.
5. Totals
•i-";*:v^K;*;i;vr.:;H:^^^ \vbK::^^;\^';x>HiV^;:::,H^>>>?
Catalog of Federal
Domestic Assistance
Number
(b)
Estimated Unobligated Funds
Federal
(0
$
$
Non-Federal
(d)
$
$
New or Revised Budget
Federal
(e)
$
$
Non-Federal
(f)
$
$
Total
(g)
$
$
"3Co^vx<^;s; o*s
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 61 and 6j)
GRANT PROGRAM, FUNCTION OR ACTIVITY
(1) (2) (3) (4)
$
$
- ' "r"?**-5 -'-* ,;»''•!**.'»',•; r'.V; ~s V ***^ ^'- \,*""^xs°!*l'M' , '•*'* , v-«v .:\ I" \ \fl*
7. Program Income
$
$
$
$
$
$
$
«. X- * - * * - V-- -. v ' - *. ,, X ^ -¥, * '* •.,-.%•.* i , , -\ X \ ^ - -" - " ^ ^ - * . , ., ,x- ^ ^ X •% ^v
$
$
$
Total
(5)
$
$
.5,-s \'V<%-, ,\ >S -%
$
Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97)
-------
(a) Grant Program
8.
9.
10,
11.
12. TOTAL (sum of lines 8-11)
(b) Applicant
(c) State
(d) Other Sources
(e) TOTALS
13. Federal
14. Non-Federal
15. TOTAL (sum of lines 13 and 14)
Total for 1st Year
1st Quarter
$
2nd Quarter
3rd Quarter
4th Quarter
$
(a) Grant Program
6.
7.
8.
9.
0. TOTAL (sum of lines 16-19)
(b) First
FUTURE FUNDING PERIODS (Years)
(c) Second
$
(d) Third
(e) Fourth
$
1. Direct Charges:
3. Remarks:
Authorized for Local Reproduction
Standard Form 424A (Rev. 7-97) Page 2
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Assurances—Non-Construction Programs
_ OMB Approval No. 0348-0040
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. 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 costs)
to ensure proper planning, management and completion of the
project described in this application.
2. Will give the awarding agency, the Comptroller General of
the 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. §§ 4728-4763) relating to prescribed stan-
dards 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 Adminis-
tration (5 C.F.R. 900, Subpart F).
6. Will comply with all Federal statutes relating to nondis-
crimination. 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. §§ 1681-1683, 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. § 794), which prohibits discrimina-
tion on the basis of handicaps; (d) the Age Discrimination
Act of 1975, as amended (42 U.S.C. §§ 6101-6107), which
prohibits discrimination on the basis of age; (e) the Drug
Abuse Office and Treatment Act of 1972 (P.O. 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 nondis-
crimination on the basis of alcohol abuse or alcoholism;
(g) § § 523 and 527 of the Public Health Service Act of 1912
(42 U.S.C. 290 dd-3 and 290 ce-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. §
36701 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) un-
der which application for Federal assistance is being made;
and (j) the requirements of any other nondiscrimination
statute(s) which may apply to the application.
7. Will comply, or has already complied, with the require-
ments 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 ac-
quired 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 partici-
pation in purchases.
8. Will comply, as applicable, with the provisions of the
Hatch Act (5 U.S.C. §§ 1501-1508 and 7324-7328) which
limit the political activities of employees whose principal
employment activities are funded in whole or in part with
Federal funds.
9. Will comply, as applicable, with the provisions of the
Davis-Bacon Act (40 U.S.C. §§ 276a and 276a-7), the
Copeland Act (40 U.S.C. § 276c and 18 U.S.C. §§ 874), and
the Contract Work Hours and Safety Standards Act (40
U.S.C. §§ 327-333), regarding labor standards for feder-
ally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase
requirements of Section 102(a) of the Flood Disaster Pro-
tection 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 insur-
able construction and acquisition is $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 Na-
tional 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; (e) evaluation of flood hazards in
flood plains in accordance with EO 11988; (e) assurance of
Previous Editions Usable
Page 1 of 2
Authorized for Local Reproduction
SF-424B (Rev, 4/92)
Prescribed by OMB Circular A-102
-------
12.
13.
project consistency with the approved State management
program developed under the Coastal Zone Management
Act of 1972 (16 U.S.C. §§ 1451 et scq.); (f) 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. § 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 Endan-
gered Species Act of 1973, as amended, (P.L. 93-205).
Will comply with the Wild and Scenic Rivers Act of 1968
(16 U.S.C. §§ 1271 et seq.) related to protecting compo-
nents or potential components of the national wild and
scenic rivers system.
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 (16 U.S.C. 469a-l et seq.).
14. Will comply with P.L. 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 the Laboratory Animal Welfare Act of
1966 (P.L. 89-544, as amended, 7 U.S.C. 2131 et 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 Preven-
tion Act (42 U.S.C. §§ 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
Applicant Organization
Title
Date Submitted
Previous Editions Usable
Page 2 of 2
Authorized for Local Reproduction
SF-424B (Rev. 4/92)
Prescribed by OMB Circular A-102
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xvEPA
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 the principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from coverage by any 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, 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 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 or cause or default.
I understand that a false statement on this certification may be ground 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 up to
$10,000 or imprisonment for up to 5 years, or both.
Typed Name & Title of Authorized Representative
Signature of Authorized Representative Date
I am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
-------
SEPA
Washington, DC 20460
Preaward Compliance Review Report for
AH Applicants Requesting Federal Financial Assistance
FORM Approved
OMB No. 2090-0014
Expires 4-30-99
Note: Read instructions before completing form.
I. A. Applicant (Name, City, State) • B. Recipient (Name, City. State)
C. EPA Project No.
II. Brief description of proposed project, program or activity.
III. Are any civil rights lawsuits or complaints pending against applicant and/or recipient? If
yes, list those complaints and the disposition of each complaint.
IV. Have any civil rights compliance reviews of the applicant and/or recipient been conducted
by any Federal agency during the two years prior to this application for activities which would
receive EPA assistance? If yes, list those compliance reviews and status of each review.
V. Is any other Federal financial assistance being applied for or is any other Federal financial
assistance being applied to any portion of this project, program or activity? If yes. list the other
Federal Agency(s), describe the associated work and the dollar amount of assistance.
Yes l_j No
1 1 Yes |_| No
Yes l_| No
VI. If entire community under the applicant's jurisdiction is not served under the existing facilities/services, or will not be
served under the proposed plan, give reasons why.
VII. Population Characteristics
1. A. Population of Entire Service Area
B. Minority Population of Entire Service Area
2. A. Population Currently Being Served
B. Minority Population Currently Being Served
3. A. Population to be Served by Project. Program or Activity
B. Minority Population to be Served by Project, Program or Activity
4. A. Population to Remain Without Service
B. Minority Population to Remain Without Service
VII. Will all new facilities or alterations to existing facilities financed by these funds be
designed and constructed to be readily accessible to and usable by handicapped persons? If no,
explain how a regulatory exception (40 CFR 7.70) applies
Number of People
Yes [_J No
!X. Give the schedule for future projects, programs or activities (or of future plans), by which services will be provided to all
beneficiaries within applicant's jurisdiction. If there is no schedule, explain why
X. I certify that the statements I have made on this form and all attachments thereto are true, accurate and complete. I
acknowledge that any knowingly false or misleading statement may be punishable by fine or imprisonment or both under
applicable law.
A. Signature of Authorised Official B. Title of Authorized Official C. Date
For the I'.S. Environmental Protection Agency
I I Approved 1 1 Disapproved Authorized EPA Official Date
EPA Form 4700-4 (Rev. 1/90) Previous editions are obsolete.
-------
United States
Environmental Protection Agency
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 app ropriated funds have been paid or wil I 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 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 documents for all sub-awards at all tiers (including sub-contracts, sub-grants,
and contracts under grants, loans, and cooperative agreements) and that all sub-
recipients 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 & Titleof Authorized Representative
Signature o f Authorized Representative Date
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Regional TAG Contacts
Region 1 [CT, MA, NH, VT, Rl, ME]
Mike McGagh
U.S. EPA Region 1 (MC:HBS)
One Congress Street
Boston, MA 02114-2023
Phone: 617-918-1428
Region 2 [NY, NJ, PR, VI]
Carol Hemington
U.S. EPA Region 2 (MC:2OPM-GCMB)
290 Broadway
New York, NY 10007-1866
Phone:212-637-3420
Region 3 [DC, DE, MD, PA, VA, WV]
Amelia Libertz
U.S. EPA Region 3 (MC:3H543)
1650 Arch Street
Philadelphia, PA 19103-2029
Phone:215-814-5522
Region 4 [AL, FL, GA, KY, MS, NC, SC, TN]
Rosemary Patton, Sharon Chandler,
Rhonda Foucher, Denise Bland
U.S. EPA Region 4 (MC:WDCSB)
Atlanta Federal Center
61 Forsyth Street
Atlanta, GA 30303-3507
Phone: 404-562-8866 (Rosemary)
Phone: 404-562-8888 (Sharon)
Phone: 404-562-8867 (Rhonda)
Phone: 404-562-8880 (Denise)
Region 5 [IL, IN, Ml, MN, OH, Wl]
Susan Pastor, Suzanne Coll
U.S. EPA Region 5 (MC:P19J)
Metcalfe Federal Bldg
77 W. Jackson Boulevard
Chicago, IL 60604
Phone: 312-353-1325 (Susan)
Phone: 312-886-6044 (Suzanne)
or 800-621-8431
Region 6 [AR, LA, NM, OK, TX]
Beverly Negri
U.S. EPA Region 6 (MC:6SF-PO)
Tower at Fountain Place
1445 Ross Ave., Suite 1200
Dallas, TX 75202-2733
Phone:214-665-8157
Region 7 [IA, KS, MO, NE]
Hattie Thomas
U.S. EPA Region 7 (MC:PBAF)
901 N. Fifth Street
Kansas City, KS66101
Phone:913-551-7762
Region 8 [CO, MT, ND, SD, UT, WY]
Linda Armer
U.S. EPA Region 8 (MC:EPR-PS)
999 18th Street, Suite 500
Denver, CO 80202-2466
Phone:303-312-6696
Region 9 [AZ, CA, HI, NV]
David Cooper
U.S. EPA Region 9 (MC:SFD-3)
75 Hawthorne Street
San Francisco, CA 94105
Phone:415-972-3237
or 800-231-3075
Region 10 [AK, ID, OR, WA]
Marianne Deppman, Debra Sherbina
U.S. EPA Region 10 (MC:ECO-081)
1200 6th Avenue
Seattle, WA98101
Phone: 206-553-1237 (Marianne)
Phone: 206-553-0247 (Debra)
Headquarters
Freya Margand, National TAG Coordinator
U.S. EPA(MC:5204G)
1200 Pennsylvania Avenue N.W.
Washington, DC 20460
Phone: 703-603-8889
55
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