STATE OF CALIFORNIA



STATE OF CALIFORNIA

STATE WATER RESOURCES CONTROL BOARD

DIVISION OF FINANCIAL ASSISTANCE

Financial Assistance Application for Construction

for the

State Revolving Fund Loan Program

Water Reclamation Loan Program

Small Community Wastewater Grant Program

This application package should be submitted to the address listed below at the completion of Facilities Planning. An agency may request funding from more than one program. The application, including attachments, is intended to provide all information and documents needed for facilities plan approval and presentation of the project to the State Water Resources Control Board for a preliminary funding commitment. Updated information will be required to be submitted later.

Please refer to the adopted Policies for program specific information.

Submit the completed application package to:

Mr. F. Wayne Pierson, Assistant Division Chief

Division of Financial Assistance

State Water Resources Control Board

1001 I Street

P.O. Box 944212

Sacramento, CA 94244-2120

State Water Resources Control Board

Division of Financial Assistance

Financial Assistance Application Checklist

Submit your Financial Assistance Application with all the documents listed below. Upon review and acceptance of your submittal, the Division of Financial Assistance will issue

a Facilities Plan or a Concept Approval Letter and will present the project to the State Water Resources Control Board for a preliminary loan or grant commitment.

|Attach- |Title of Attachment |Application Reference |

|ment No. | | |

| |

|Submit the following documents for all Financial Assistance Programs |

|1 |Project Description |Section II.1 |

|2 |Sources of Funds for Capital Costs |Section II.7 |

|3 |Legal Authority |Section III.1 |

|4 |Application/Authorization/Reimbursement Resolution |Section III.2 |

|5 |Project Report or Facilities Planning Document |Section III.4 |

|6 |Environmental Review |Section III.5 |

|7 |Draft Revenue Program |Section III.6 |

|8 |Project Schedule |Section III.7 |

|9 |Regional Board Requirements (Waste Discharge Req.) |Section III.8 |

|10A |Real Property Acquisition |Section III.9 |

|10B |Agreements with Other Parties |Section III.10 |

|10C |Tax Questionnaire |Section III.11 |

|SRF Loan Program only (include, in addition to the items 1 through 10 above, the following documents) |

|11 |Water Conservation Plan |Section IV.A.1 |

|12 |Dedicated Source of Revenue |Section IV.A.2 |

|13 |Certification of Compliance With Federal Laws and Authorities (Federal Laws) |Section IV.A.3 |

|14 |Pre-award Compliance Report (Civil Rights Compliance) |Section IV.A.4 |

|WRLP only (include, in addition to the items 1 through 10 above, the following documents) |

|15 |Reclaimed Water User Assurances |Section IV.B.3 |

Attachment 4

APPLICATION/AUTHORIZATION/REIMBURSEMENT

RESOLUTION(S) MODEL

(Note: The Model Resolution is shown as one Agency action but may be done as multiple Resolutions if required by Agency)

RESOLUTION NO.

APPLICATION/AUTHORIZED REPRESENTATIVE RESOLUTION

BE IT RESOLVED by the (Governing Board of the Agency) that the (Title of Authorized Representative) hereby authorized and directed to sign and file, for and on behalf of the (Agency Name ) , a Financial Assistance Application for a loan/grant from the State Water Resources Control Board in the amount not to exceed (Amount) , for the planning, design, and construction of (Project Title or Description) , and

BE IT RESOLVED that the (Agency Name) hereby agrees and further does authorize the aforementioned representative or his/her designee to certify that the Agency has and will comply with all applicable state and federal statutory and regulatory requirements related to any federal and state loan/grants received, and

BE IT FURTHER RESOLVED that the (Authorized Representative) or his/her designee of the (Agency Name) is hereby authorized to negotiate and execute a loan/grant contract and any amendments or change orders thereto and certify loan/grant disbursements on behalf of the (Agency Name) .

REIMBURSEMENT RESOLUTION

WHEREAS, the NAME OF RECIPIENT (the "Agency") desires to finance the costs of constructing and/or reconstructing certain public facilities and improvements relating to its water and wastewater system, including certain treatment facilities, pipelines and other infrastructure (the "Project"); and

WHEREAS, the Agency intends to finance the construction and/or reconstruction of the Project or portions of the Project with moneys ("Project Funds") provided by the State of California, acting by and through the State Water Resources Control Board (SWRCB); and

WHEREAS, the SWRCB may fund the Project Funds with proceeds from the sale of obligations the interest upon which is excluded from gross income for federal income tax purposes (the "Obligations"), and

WHEREAS, prior to either the issuance of the Obligations or the approval by the SWRCB of the Project Funds the Agency desires to incur certain capital expenditures (the "Expenditures") with respect to the Project from available moneys of the Agency; and

WHEREAS, the Agency has determined that those moneys to be advanced on and after the date hereof to pay the Expenditures are available only for a temporary period and it is necessary to reimburse the Agency for the Expenditures from the proceeds of the Obligations;

NOW, THEREFORE, THE AGENCY DOES HEREBY RESOLVE, ORDER AND DETERMINE AS FOLLOWS:

SECTION 1. The Agency hereby states its intention and reasonably expects to reimburse Expenditures paid prior to the issuance of the Obligations or the approval by the Board of the Project Funds.

SECTION 2. The reasonably expected maximum principal amount of the Project Funds is $_____________. {Note: The Division of Financial Assistance may provide up to 150 percent of the Preliminary Loan Commitment without having to go back to the Board or Division Chief for reauthorization. Also, the amount stated here cannot be exceeded by Division unless superceded by Resolution.}

SECTION 3. This resolution is being adopted no later than 60 days after the date on which the Agency will expend moneys for the portion of the Project costs to be reimbursed with Project Funds.

SECTION 4. Each Expenditure by the Agency will be of a type properly chargeable to a capital account under general federal income tax principles.

SECTION 5. To the best of our knowledge, this Agency is not aware of the previous adoption of official intents by the Agency that have been made as a matter of course for the purpose of reimbursing expenditures and for which tax-exempt obligations have not been issued.

SECTION 6. This resolution is adopted as official intent of the Agency in order to comply with Treasury Regulation §1.150-2 and any other regulations of the Internal Revenue Service relating to the qualification for reimbursement of Project costs.

SECTION 7. All the recitals in this Resolution are true and correct and this Agency so finds, determines and represents.

AYES:

NOES:

ABSENT:

CERTIFICATION

I do hereby certify that the foregoing is a full, true, and correct copy of a resolution duly and regularly adopted at a meeting of the (Governing Board of the Agency)

held on (Date) .

ATTEST AND SEAL:

TITLE

(Clerk or Authorized Record Keeper of the Governing Board of the Agency)

Attachment 13

(SRF only)

CERTIFICATION OF COMPLIANCE WITH

FEDERAL LAWS AND AUTHORITIES

ENVIRONMENTAL:

1. Archaeological and Historic Preservation Act of 1974, PL 93-291

2. Clean Air Act, 42 U.S.C. 7506(c)

3. Coastal Barrier Resources Act, 16 U.S.C. 3501 et seq.

4. Coastal Zone Management Act of 1972, PL 92-583, as amended

5. Endangered Species Act 16 U.S.C. 1531, et seq.

6. Executive Order 11593, Protection and Enhancement of the Cultural Environment

7. Executive Order 11988, Floodplain Management

8. Executive Order 11990, Protection of Wetlands

9. Farmland Protection Policy Act, 7 U.S.C. 4201 et seq.

10. Fish and Wildlife Coordination Act, PL 85-624, as amended

11. National Historic Preservation Act of 1966, PL 89-665, as amended

12. Safe Drinking Water Act, Section 1424(e), PL 92-523, as amended

13. Wild and Scenic Rivers Act, PL 90-542, as amended

ECONOMIC AND MISCELLANEOUS AUTHORITIES:

1. Demonstration Cities and Metropolitan Development Act of 1966, PL 89-754, as amended

2. Section 306 of the Clean Air Act and Section 508 of the Clean Water Act, including Executive Order 11738, Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect to Federal Contracts, Grants, or Loans

3. Uniform Relocation and Real Property Acquisition Policies Act of 1970, PL 91-646

4. Executive Order 12549 - Debarment and Suspension

SOCIAL POLICY AUTHORITIES:

1. Age Discrimination Act, PL 94-135

2. Title VI of the Civil Rights Act of 1964, PL 88-352

3. Section 13 of PL 92-500; Federal Water Pollution Control Act Amendments of 1972

4. Rehabilitation Act of 1973, PL 93-112 (including Executive Orders 11914 and 11250)

5. Drug-Free Workplace Act of 1988, Pub. L. 100-690 (applies only to the capitalization grant recipient)

6. Executive Order 11246, Equal Employment Opportunity

7. Executive Orders 11625 and 12138, Women's and Minority Business Enterprise

8. Section 129 of the Small Business Administration Reauthorization and Amendment Act of 1988, Pub. L. 100-590

9. Anti-Lobbying Provisions (40 CFR Part 30) [applies only to the capitalization grant recipient]

I certify that the________________________________________________________________

(MUNICIPALITY)

has or will comply with the above Federal Laws and Authorities

________________________________________________

Signature of Authorized Representative or Designee.

Attachment 14 (SRF only)

|United States Environmental Protection Agency | |

|Washington, DC 20460 |Form Approved |

|EPA Pre-award Compliance Review Report for |OMB No. 2090-0014 |

|Wastewater Treatment Construction Loans | |

|Note: Read Instructions on Reverse Before Completing Form |

|A. Applicant (Name and State) |B . EPA Project No. |

| | |

|II. A. Are any civil rights lawsuits or complaints pending against applicant? |

|If "Yes", list those complaints and the disposition of each complaint. |

| |

|II. B. Have any civil rights compliance reviews been conducted 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. |

| |

|III. A. Population Characteristics |Number of People |

|1. a. Population of Entire Service Area | |

| b. Minority Population of Entire Service Area | |

|2. a. Population Currently Served | |

| b. Minority Population Currently Being Served | |

|3. a. Population to be Served by Project | |

| b. Minority Population to be Served by Project | |

|4. a. Population to Remain Without Service | |

| b. Minority Population to Remain Without Service | |

|If entire community under the applicant's jurisdiction is not served under the existing facilities or will not be served under the proposed plan, give reasons |

|why. |

| |

| |

|Give the schedule for future construction by which treatment system service will be provided to all inhabitants within applicant's jurisdiction. If there is |

|no schedule, explain why. |

| |

| |

|D. Is another Federal Agency being asked or already providing financial assistance to any construction associated with this project? |

|If "Yes", list the other Federal Agency(s), describe the associated work and the dollar amount of assistance. |

| |

| |

|E. Will all new facilities or alterations to existing facilities financed by this grant be designed and constructed to be readily accessible and useable by |

|handicapped persons? |

|If "No", explain how a regulatory exception (40 CFR 7.70) applies. |

| |

| |

|IV. Certification |

|I certify that the information given above is true and correct to the best of my knowledge or belief. |

|(A willfully false statement is punishable by law; U.S. Code, Title 18, Section 1001) |

|A. Signature of Authorized Official |B. Title of Authorized Official |C. Date |

| | | |

|For the U. S. Environmental Protection Agency Use |

| |Regional Director of Civil Rights |Date |

| | | |

EPA Form 4700-4 (Rev. 2-01) Previous editions are obsolete

INSTRUCTIONS

General

Grantees must comply with the following statutes by virtue of receiving the grant.

Title VI of the Civil Rights Act of 1964 provides that no person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. The Act goes on to explain that the title shall not be construed to authorize action with respect to any employment practice of any employer, employment agency, or labor organization (except where a primary objective of the Federal financial assistance is to provide employment).

Section 13 of the 1972 Amendments to the Federal Water Pollution Control Act provides that no person in the United States shall, on the ground of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving financial assistance under the Federal Water Pollution Control Act, as amended. Employment discrimination on the basis of sex is prohibited in all such programs or activities.

Section 504 of The Rehabilitation Act of 1973 provides that no otherwise qualified handicapped individual shall solely by reason of their handicap be excluded from participation in, be denied the benefit of or be subject to discrimination under any program or activity receiving Federal financial assistance. Employment discrimination on the basis of handicap is prohibited in all such programs or activities.

The Age Discrimination Act of 1975 provides that no person on the basis of age shall be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program or activity receiving Federal financial assistance. Employment discrimination is not covered. Age Discrimination in employment is prohibited by the Age discrimination in Employment Act administered by the Equal Employment Opportunity Commission.

Title IX of the Education Amendments of 1972 provides that no person should, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving Federal financial assistance. Employment discrimination on the basis of sex is prohibited in all such education programs or activities. Note: an education program or activity is not limited to only those conducted by a formal education institution.

The primary purpose of the treatment works construction grant program under the Federal Water Pollution Control Act, as amended, is development of water pollution control facilities.

Accordingly, the information on this form is required to enable the U.S. Environmental Protection Agency to determine whether prospective treatment works construction grantees are developing treatment system projects on a nondiscriminatory basis as required by the above referenced statutes.

Submit this form with the original and required copies of applications, requests for extensions, requests for increase of funds, etc. Updates of information are all that are required after the initial application submission. If any items is not relevant to the project for which assistance is requested, write "NA" for "Not Applicable."

ITEMS

I. Self-explanatory.

II. A. 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 or entity which actually benefits from the grant. For example, if a city is the named applicant but the grant will actually benefit the Department of Sewage, only civil rights lawsuits involving the Department of Sewage whether named as a party or not should be listed.

II. B. Civil Rights compliance review means any review assessing the applicant's compliance with laws prohibiting discrimination on the basis of race, color, national origin, sex, age, or handicap. If any part of the review covered the entity which actually benefits from the grant, it should be listed. If it did not, the review should not be listed.

III. A. Give population of Applicant's treatment system jurisdiction, broken out by categories as specified.

III. B. If there is a significant disparity between minority and nonminority populations to receive service, not otherwise satisfactorily explained, the Regional office may require a map which indicates the minority and nonminority population served and not served as well as the minority and nonminority population served by this project.

III. C. "Jurisdiction" means the geographical area over which Applicant has authority to provide treatment works service.

III. D.&E. Self-explanatory.

IV. Self-explanatory.

4/01 L:\FacPlan\SRF\APPINST.doc

EPA Form 4700-4 (Rev. 4-01) Reverse

CLEAN WATER STATE REVOLVING FUND PROGRAM

of the

STATE OF CALIFORNIA

acting by and through the

STATE WATER RESOURCES CONTROL BOARD

TAX QUESTIONNAIRE

You have applied for financing from the State Water Resources Control Board (“SWRCB”) and its Clean Water State Revolving Fund (“CWSRF”.) The CWSRF utilizes the proceeds of tax-exempt bonds (the "Bonds"). Since the Bonds will be tax-exempt, it is necessary to obtain certain information regarding the project to be funded (the "Project"). This Tax Questionnaire is designed to assist in obtaining such information. Each recipient of a CWSRF loan or other assistance to be financed with Bond proceeds is requested to complete the attached Questionnaire. In addition, you will be asked to execute a certification as to the use of the financial assistance being provided to you and certain other matters that could affect the tax exemption of the Bonds. We will prepare this certification based upon the information furnished by you in this Tax Questionnaire. Your loan contract (the "Agreement"), also known as an Installment Sales Agreement, will also contain tax covenants based in part on your answers to this Tax Questionnaire.

Any questions regarding this Tax Questionnaire may be directed to your project manager. You may also wish to consult with your own counsel.

Please return a hard copy version of the executed, completed Tax Questionnaire to your project manager at State Water Resources Control Board, Division of Financial Assistance, 1001 I Street, 16th Floor, Sacramento, California 95814.

|STATE WATER RESOURCES CONTROL BOARD |

|CLEAN WATER STATE REVOLVING FUND PROGRAM |

|TAX QUESTIONNAIRE |

|LEGAL NAME OF APPLICANT |Project Number |DATE/TIME RECEIVED BY SWRCB |

|      |      | |

|NAME AND LOCATION OF PROJECT |

|      |

|As used in this Tax Questionnaire, the term "Project" is the project that you described in the Financial Assistance Application submitted to the SWRCB and |

|constitutes those costs that will be funded by the SWRCB under the Agreement. The phrase "Non-Governmental Entity" constitutes any person, partnership, |

|corporation or other organization that is not organized as a state, city, county, school district, other special district or joint powers authority. The federal |

|government is a Non-Governmental Entity. |

|Instructions: Answer all questions and provide all information and documents requested. Begin typing in the shaded area and the space will enlarge to accommodate|

|the information that is typed. |

|Briefly describe the Project, its functions and its principal components. |

| |

|      |

|Indicate by principal components your current estimates of the costs of the Project, as follows: |

| |

|a. Construction costs $      |

|b. Equipment costs $      |

|c. Rehabilitation or renovation of facilities $      |

|d. Site preparation costs $      |

|e. Architectural/engineering, design and planning costs $      |

|f. Engineering and administrative costs during construction $      |

|g. Surveys $      |

|h. Legal fees $      |

|i. Financing costs $      |

|j. Commitment fees and deposits $      |

|k. Other costs (please specify) $      |

| Yes No |

| |

|Will any portion of the financing provided under the Agreement be used to refinance existing debt relating to the Project? |

|(If yes, please identify the existing indebtedness to be refinanced, including its name, original issue date, par amount, purpose(s), whether it is immediately |

|prepayable, and whether the interest on such existing debt is federally taxable or tax-exempt. State the amount of the Agreement that is expected to be used for |

|refinancing purposes. Note that existing indebtedness includes all bonds, notes, leases or commercial paper issued by you relating to any portion of the Project.)|

| |

|      |

|Indicate the amount of Project costs that are expected to be paid within the following periods of time: |

|(Please respond to this question using the expected initiation date of construction.) |

| |

|Project costs to be spent within 6 months: $      |

|Project costs to be spent within 12 months: $      |

|Project costs to be spent within 18 months: $      |

|Project costs to be spent within 24 months: $      |

|Project costs to be spent within 30 months: $      |

|Project costs to be spent within 36 months: $      |

|Project costs to be spent beyond 36 months: $      |

|Please provide the dates of expected commencement and completion of construction of the Project. |

| |

|      |

| Yes No |

| |

|Have any costs of the Project been paid prior to the date hereof? |

|(For each Project cost that has been previously paid, provide an itemization of the (i) amount, (ii) purpose, (iii) date paid, and (iv) source of payment of such |

|cost, e.g., revenue, Federal or State grants, other financing, or internal loan.) |

|      |

| Yes No Not Applicable |

| |

|If you answered "yes" to Question 6 above, have you at any time adopted a resolution or other official action (e.g., a so-called "reimbursement resolution") |

|relating to your intent to finance the Project with financial assistance from the SWRCB or other indebtedness? |

|(If yes, please identify the date of such resolution or other document and attach a copy.) |

| |

|      |

| Yes No |

| |

|Will any portion of the financing provided under the Agreement be used to pay administrative or engineering expenses directly relating to the construction of the |

|Project? |

|(If yes, please state the amount expected to be so used and provide details as to its calculation (e.g., based on actual costs or a percentage of construction).) |

| |

|      |

| Yes No Not Applicable |

| |

|If you answered "yes" to Question 8 above, will any portion of the financing provided under the Agreement be used to pay administrative or engineering expenses |

|incurred by the applicant’s staff? |

|(If yes, please state the amount expected to be so used and provide details of the work performed.) |

| |

|      |

| Yes No Not Applicable |

| |

|If you answered "yes" to Question 9 above, will the charges to be reimbursed be tracked by an accounting system, such as a cost accounting system, that will allow |

|them to be differentiated from other charges for other work done by the applicant’s staff? |

|(If yes, please specify how charges will be tracked.) |

| |

|      |

| Yes No |

| |

|Do you anticipate any Non-Governmental Entity owning any portion of the Project at any time? |

|(If yes, identify the Non-Governmental Entity and provide all available details with respect to its ownership interest.) |

| |

|      |

| Yes No |

| |

|Do you anticipate any Non-Governmental Entity contracting to operate, manage, or provide any exclusive services with respect to the Project at any time? |

|(If yes, please identify the Non-Governmental Entity and explain the arrangement. If an operations, management, or exclusive services contract currently exists, |

|attach a copy. Contracts that relate solely to services that are merely incidental to the primary use of the Project need not be listed. Examples of incidental |

|services are contracts for janitorial services, office equipment repairs, or billing services. If you are uncertain as to whether the contract is incidental or |

|not, please describe the contract and the services provided thereunder.) |

| |

|      |

| Yes No |

| |

|Will the Project provide recycled water or wastewater services to non-governmental entities other than on the basis of standard rates and charges? |

|(If there are any non-standard rates and charges, describe the rate structure focusing on any special rate agreements or charges for specific entities. An example|

|of a non-standard rate is a large industrial user paying a flat fee in a system where the other users pay a rate based on usage.) |

| |

|      |

| Yes No |

| |

|Do you anticipate any Non-Governmental Entity having special priority rights or other preferential rights to use the service provided by the Project? |

|(If yes, identify the Non-Governmental Entity and describe the special priority or preferential right(s).) |

| |

|      |

| Yes No |

| |

|Will the entire Project be available for use by the general public? |

|(If no, please explain and describe the portion of the Project that will not be available for use by the general public. For example, municipal water and |

|wastewater systems used for residential, commercial, governmental, and business purposes are available for use by the general public; a specialized pollution |

|control facility immediately adjacent to a private business that is the sole user of the facility is not available for use by the general public.) |

| |

|      |

| Yes No |

| |

|Will any Non-Governmental Entity guaranty or otherwise be directly obligated to repay the financial assistance provided under the Agreement? |

|(If yes, identify the Non-Governmental Entity and describe the guaranty arrangement therewith.) |

| |

|      |

|APPLICANT ACKNOWLEDGEMENT AND SIGNATURE |

| |

|I hereby certify that I am an authorized representative of the Applicant, and that I am authorized by the Applicant to execute this Tax Questionnaire. I am |

|charged with the responsibility to perform such acts as are necessary and proper for the financing, construction, acquisition, and/or improvement of the Project, |

|and am acting for and on behalf of the Applicant in executing this Tax Questionnaire. I certify that I am familiar with the Project and that all information |

|contained herein is true, correct, and complete to the best of my knowledge. I am not aware of any facts or circumstances that would cause me to question the |

|accuracy or reasonableness of any information contained in these responses or attached documentation. I understand that the foregoing information and attached |

|documentation will be relied upon by the SWRCB and their counsel, in providing financing with respect to the Project. |

| |

|AUTHORIZED REPRESENTATIVE SIGNATURE |PRINT NAME AND TITLE |DATE |

| |      |      |

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