HOUSEHOLD HAZARDOUS WASTE GRANT APPLICATION INDIANA HOUSEHOLD HAZARDOUS WASTE GRANT PROGRAM Office of Pollution Prevention and Technical Assistance INDIANA HHW GRANT PROGRAM 100 North Senate Avenue, MC 64-01 Indianapolis, IN 46207-7095 State Form 51899 (R / 8-07) Indiana Department of Environmental Management Internet: www.recycle.in.gov/funding/hhwg.html INSTRUCTIONS: For assistance call your regional grant representative at the Office of Pollution Prevention and Technical Assistance, Source Reduction and Recycling Branch (800-988-7901). Please print or type. SECTION 1 APPLICANT INFORMATION Program administrator (contact person) Ms. Mr. Phone: Title: Fax: Official name of agency or organization: E-Mail: Federal ID Number: County (ies): Address: City: ZIP Code + 4: Official Signatory for Applicant: Position: Address: Mayor City: Board Chairperson President Commissioner Executive Director ZIP code + 4: SECTION 2 PROJECT SUMMARY Please shade area served or attach map showing area to be served. SECTION 3 GRANT DATA Target number of households Target population: If school, target number of students Total project cost SECTION 4 Pounds of material to be diverted through project: $ Funds requested $ TYPE OF APPLICANT (Check the appropriate box) Joint application; attach participant list Solid Waste Management District School (K-12) University County Non-profit City Town SECTION 5 SIGNATURE I certify that submission of this application has been duly authorized by the governing body of the entity and that I am legally authorized by the governing body to sign the application. Signature of applicant representative Printed name Date (month, day, and year) American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS: Round amounts up to whole dollars. A dollar for dollar cash match is required for disposal cost and equipment purchases. If grant is awarded, an approved budget page will be included in Exhibit B of the grant agreement. SECTION 6 PROPOSED BUDGET Grant Request Cash Match In-Kind Total Personnel $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Project/Equipment Costs Operating/Program Costs Contractor/Professional Fees Education/Promotion Costs Enter column totals in boxes below. $ $ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS: Applications are evaluated based on the responses to the questions listed in categories I-IV. Each response must be complete and numbered; please attach the application question responses to the cover page, proposed budget, and any other applicable materials being submitted. SECTION 7 HHW GRANT APPLICATION QUESTIONS I. Project Description 1) Describe the proposed project, including its goals and objectives. 2) Provide anticipated project plan timeline (e.g., activity occurs months 1-3, months 4-6, months 7-9, etc.). Describe the activities planned to accomplish the objectives. 3) Will the project provide a new service that is currently not available in the area or expand participation in a program? What area and population will the program serve? How many households or CESQGs do you expect the program to serve in its first (or next) full year of operation? 4) Provide the location(s) of activity, facility or event operating hours and/or collection schedule. 5) Describe how the project relates to other programs or services that you provide, and whether the project will enhance existing programs or services. 6) Provide locations (addresses) for grant funded equipment already owned by your organization, recycling drop-off sites, and household hazardous waste collection sites or facilities in your area, plus hours of operation. II. Waste Management and Diversion 1) How will material(s) be collected, stored, transported and disposed? Indicate which tasks program staff will perform and which the contractor will perform. 2) Please list materials to be collected by the project and any new materials to be added. How many pounds of HHW or CESQG waste do you expect to divert to proper disposal because of this project? 3) What is the method of final disposal used for each material collected: incineration, treatment, or recycling? (attach a chart if necessary) 4) How will you ensure that collected waste is recycled or properly disposed? 5) Describe your plan for staff training to meet safety and regulatory requirements. 6) What materials will be recycled or offered for reuse? 7) Describe the background, training, and technical expertise for key project personnel (either applicant or contractor) through resumes, background statements, references, etc. 8) Provide the company name, address, phone and contact person for all contractor(s) or disposal facilities to be used. III. Education Plan 1) Describe the goals of your education and/or promotion plan. 2) Describe project’s education plan and target audience, including media to be used, education and promotion message, frequency of message, and how the target audience will be informed about proper participation. 3) Describe project’s source reduction message or component. 4) Identify any education partners who will be participating, and what each partner will contribute to the education plan. How are local waste water facilities participating in the project? IV. Project Sustainability 1) Explain all budget page line items (grant requests, cash, and in-kind matching columns). Quotes and spec sheets are required for all equipment purchases. If you are proposing to purchase or trade-in used equipment, an appraisal of the equipment will be required to be submitted to IDEM for approval prior to the transaction. 2) Describe the roles and monetary and in-kind contributions of partners involved in the project. 3) Describe cost and program efficiencies realized by project implementation (e.g., savings in manpower, fuel, contractor and transportation cost, etc.). 4) Describe your plan for funding the continuation of the program after the end of the grant term. Identify sources of revenue, such as user fees, tax revenue, tipping fee revenue, etc. 5) Applicants requesting funding for equipment purchases must establish a maintenance plan and a capital improvement fund to replace the equipment at the end of its useful life. Please identify specific maintenance requirements of the equipment. Describe your plan for maintenance of the equipment and for establishing a capital improvement fund for repair and replacing the equipment. 6) Explain your plan for evaluating of the effectiveness of the equipment to be purchased, if funding is requested for an equipment purchase. 7) What is the plan for evaluating the implementation and outcome of the proposed program and who is the person responsible for performing the evaluation? 8) What criteria and methods will be use for measuring and determining the success of the proposed program? American LegalNet, Inc. www.FormsWorkflow.com