+-------------------+---+---+-------------------+------+---+--------------+
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+-------------------+---+---+-------------------+------+---+--------------+
| Note: Read        |   |   |                   |      |   |              |
| Instructions      |   |   |                   |      |   |              |
| before completing |   |   |                   |      |   |              |
| form.             |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| 1\. A. Applicant  |   |   | B. Recipient      |      |   | C. EPA       |
| (Name, City,      |   |   | (Name, City,      |      |   | Project No.  |
| State)            |   |   | State)            |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| II\. Brief        |   |   |                   |      |   |              |
| description of    |   |   |                   |      |   |              |
| proposed project, |   |   |                   |      |   |              |
| program or        |   |   |                   |      |   |              |
| activity.         |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| III\. Are any     |   |   |                   |      |   | Yes          |
| civil rights      |   |   |                   |      |   |              |
| lawsuits or       |   |   |                   |      |   | No           |
| complaints        |   |   |                   |      |   |              |
| pending against   |   |   |                   |      |   |              |
| applicant and/or  |   |   |                   |      |   |              |
| recipient? If     |   |   |                   |      |   |              |
| yes, list those   |   |   |                   |      |   |              |
| complaints and    |   |   |                   |      |   |              |
| the disposition   |   |   |                   |      |   |              |
| of each           |   |   |                   |      |   |              |
| complaint.        |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| IV\. Have any     |   |   |                   |      |   | Yes          |
| civil rights      |   |   |                   |      |   |              |
| compliance        |   |   |                   |      |   | No           |
| 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   |   |   |                   |      |   | Yes          |
| Federal financial |   |   |                   |      |   |              |
| assistance being  |   |   |                   |      |   | No           |
| 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),        |   |   |                   |      |   |              |
| described the     |   |   |                   |      |   |              |
| associated work   |   |   |                   |      |   |              |
| and the dollar    |   |   |                   |      |   |              |
| amount of         |   |   |                   |      |   |              |
| assistance.       |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| VI\. If entire    |   |   |                   |      |   |              |
| community under   |   |   |                   |      |   |              |
| the applicant's   |   |   |                   |      |   |              |
| jurisdiction is   |   |   |                   |      |   |              |
| not served under  |   |   |                   |      |   |              |
| the existing      |   |   |                   |      |   |              |
| fac               |   |   |                   |      |   |              |
| ilities/services, |   |   |                   |      |   |              |
| or will not be    |   |   |                   |      |   |              |
| served under the  |   |   |                   |      |   |              |
| proposed plan,    |   |   |                   |      |   |              |
| give reasons why. |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| VII\. Population  |   |   |                   |      |   | Number of    |
| Characteristics   |   |   |                   |      |   | People       |
+-------------------+---+---+-------------------+------+---+--------------+
| 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 With       |   |   |                   |      |   |              |
| Service           |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| VIII\. Will all   |   |   |                   |      |   | Yes          |
| new facilities or |   |   |                   |      |   |              |
| alterations to    |   |   |                   |      |   | No           |
| existing          |   |   |                   |      |   |              |
| facilities        |   |   |                   |      |   |              |
| financed by these |   |   |                   |      |   |              |
| funds be designed |   |   |                   |      |   |              |
| and constructed   |   |   |                   |      |   |              |
| to be readily     |   |   |                   |      |   |              |
| accessible to and |   |   |                   |      |   |              |
| usable by         |   |   |                   |      |   |              |
| handicapped       |   |   |                   |      |   |              |
| person? If no,    |   |   |                   |      |   |              |
| explain how a     |   |   |                   |      |   |              |
| regulatory        |   |   |                   |      |   |              |
| exception (40 CFR |   |   |                   |      |   |              |
| 7.70) applies.    |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| 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  |   |   |                   |      |   |              |
| 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   |   | B |                   | C.   |   |              |
| Authorized        |   | . |                   | Date |   |              |
| Official          |   | T |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | t |                   |      |   |              |
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|                   |   | o |                   |      |   |              |
|                   |   | f |                   |      |   |              |
|                   |   | A |                   |      |   |              |
|                   |   | u |                   |      |   |              |
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|                   |   | h |                   |      |   |              |
|                   |   | o |                   |      |   |              |
|                   |   | r |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | z |                   |      |   |              |
|                   |   | e |                   |      |   |              |
|                   |   | d |                   |      |   |              |
|                   |   | O |                   |      |   |              |
|                   |   | f |                   |      |   |              |
|                   |   | f |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | c |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | a |                   |      |   |              |
|                   |   | l |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| **For the U.S.    |   |   |                   |      |   |              |
| Environmental     |   |   |                   |      |   |              |
| Protection        |   |   |                   |      |   |              |
| Agency**          |   |   |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+
| Approved          |   | A |                   | Date |   |              |
|                   |   | u |                   |      |   |              |
| Disapproved       |   | t |                   |      |   |              |
|                   |   | h |                   |      |   |              |
|                   |   | o |                   |      |   |              |
|                   |   | r |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | z |                   |      |   |              |
|                   |   | e |                   |      |   |              |
|                   |   | d |                   |      |   |              |
|                   |   | E |                   |      |   |              |
|                   |   | P |                   |      |   |              |
|                   |   | A |                   |      |   |              |
|                   |   | O |                   |      |   |              |
|                   |   | f |                   |      |   |              |
|                   |   | f |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | c |                   |      |   |              |
|                   |   | i |                   |      |   |              |
|                   |   | a |                   |      |   |              |
|                   |   | l |                   |      |   |              |
+-------------------+---+---+-------------------+------+---+--------------+

EPA Form 4700-4 (Rev. 1/90) Previous editions are obsolete.