ࡱ> sur% &bjbj%% @XGGFlX X X X X X X $| P|x<| 0V(~~~~ ".......$0  3/X #~~##/#X X ~~/####.X ~X ~.##.#N#):R.,X X .~ `| 0 J#^~. ./00.R3#3.#| | X X X X APPLICATION FORM FOR HARDSHIP DESIGN ADVANCE FROM THE UTAH STATE WATER QUALITY BOARD Application Number: (LEAVE BLANK-FOR STATE USE ONLY) Preapplication Meeting Date: PROJECT IDENTIFICATION AND DESCRIPTION 1. APPLICANT:  FORMTEXT       (Municipality, Sewer District, Special Improvement District, etc.) Address:  FORMTEXT       Phone:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       EIN #  FORMTEXT       2. PRESIDING OFFICIAL:  FORMTEXT       (Name and Title) 3. CONTACT PERSON:  FORMTEXT       (Name and Title) Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       4. TREASURER/RECORDER:  FORMTEXT       (Name and Title) 5. CONSULTING ENGINEER:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       6. CITY ATTORNEY:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       7. BOND COUNSEL:  FORMTEXT       (Name and Title) Name of Firm:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT       For the following questions please attach explanations on a separate sheet if adequate space is not provided on this form. 8. GENERAL PROJECT OVERVIEW Briefly describe the plan of study proposed:  FORMTEXT       Date draft plan was submitted to DWQ:  FORMTEXT       Date final plan was approved by DWQ:  FORMTEXT       B. Estimated plan completion date:  FORMTEXT       C. Estimated construction completion date:  FORMTEXT       D. Position on the Utah Priority List # FORMTEXT       List Date:  FORMTEXT       E. Explain the financial hardship your community would experience if a design advance is not provided to complete design:  FORMTEXT       F. What good faith efforts have been made to secure all or part of services and funds from other funding agencies?  FORMTEXT       9. COST ESTIMATED FOR DESIGN SERVICES: A. Consulting Engineer: $  FORMTEXT       B. Other Consultants: $  FORMTEXT       C. Administration: $  FORMTEXT       D. Legal: $  FORMTEXT       E. Other:  FORMTEXT       $  FORMTEXT       F. Other:  FORMTEXT       $  FORMTEXT       G. Other:  FORMTEXT       $  FORMTEXT       H. Other:  FORMTEXT       $  FORMTEXT       TOTAL ESTIMATED COST $  FORMTEXT       (ATTACH COPIES OF DRAFT CONTRACTS) 10. SOURCES OF FUNDING (other than the WQB design advance): A. Local Contribution $  FORMTEXT       B. Other: FORMTEXT       $  FORMTEXT       C. Other: FORMTEXT       $  FORMTEXT       D. Other: FORMTEXT       $  FORMTEXT       E. Other: FORMTEXT       $  FORMTEXT       TOTAL SOURCES OF FUNDING $  FORMTEXT       11. AMOUNT OF THIS APPLICATION: $  FORMTEXT       APPLICATION FOR UTAH WATER QUALITY BOARD DESIGN ADVANCE PART II If the applicant accepts a design advance from the Water Quality Board Hardship Grant Program the following conditions apply: 1. The applicant must commit to complete the project design in accordance with the approved planning document. 2. Grant funds will be used only to pay for project costs as defined in R317-101-2 (D) of the Utah State Administrative Code. 3. The Water Quality Board will require the applicant to repay the design advance to the Hardship Grant Fund at the time construction financing is secured. 4. All project funds will be deposited into a supervised escrow account of the applicant's choice. All disbursements from the account will be reviewed and approved by the applicant and the Division of Water Quality. Contractors and vendors will be paid directly from the account upon authorization. 5. Engineering design services must be procured in accordance with rules defined in R33-5 of the Utah State Administrative Code. 6. Any increases to the original grant award must be authorized by the Water Quality Board. Costs incurred beyond the authorized amount or beyond the scope of work agreed to by the Water Quality Board shall be the sole responsibility of the applicant. 7. The applicant will designate a representative or representatives to assist their consultants and the State in coordinating design efforts with the community's governing board. 8. If the project is not proceeding in accordance with the agreed upon schedule the grant may be withdrawn and the applicant required to refund the design advance. I hereby certify that, to the best of my knowledge and belief, representations in this application are true and correct, the document has been duly authorized by the governing body of the applicant, and the applicant will comply with the terms, conditions and assurances if the design advance is awarded. 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0^`0a$$a$$a$$$$$$$%&&(&N&&&&& *$ !%a$$ ) `0KP !$`'0*a$#$ ;`0Kp@ P !$`'0*a$ N&P&\&^&`&b&j&l&&&&&&&CJ0J+mHnHu0J+ j0J+U ...()()()..)()P/ =!8"8#8$8%8$...()()()..)()P/ =!8"8#8$8%8$D4Text1MType name of Municipality, Sewer District, Special Improvement District, etc.MType name of Municipality, Sewer District, Special Improvement District, etc.D4Text2AddressAddressD4Text3PhonePhoneD4Text4CityCityDText5Zip CodeZip CodeDText6EIN #EIN #D*Text7$Name and Title of Presiding Official$Name and Title of Presiding OfficialD*Text8 Name and Title of Contact Person Name and Title of Contact PersonD4Text145AddressAddressD(Text147CityCityDText148Zip CodeZip CodeD4Text146PhonePhoneD*Text9$Name and Title of Treasurer/Recorder$Name and Title of Treasurer/Recorder D*Text10%Name and Title of Consulting Engineer%Name and Title of Consulting EngineerD4Text16#Name of Consulting Engineering Firm#Name of Consulting Engineering FirmD4Text11AddressAddressD4Text13CityCityDText14Zip CodeZip CodeD4Text12PhonePhone 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