Approved By OMB: No. 2030-0020 Expires 04-30-201 2

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### United States Environmental Protection Agency Washington, DC 20460

Preaward Compliance Review Report for
All Applicants and Recipients Requesting EPA Financial Assistance

Note : Read instructions on other side before completing form.

I. Applicant/Recipient (Name, Address, State, Zip Code). DUNS No.

II. Is the applicant currently receiving EPA assistance?

III. List all civil rights lawsu its and administrative complaints pending agains t the applicant/recipient that allege discrimin ation based on race, color, national origin, sex, age, or disability. (Do not includ e employment complaints not covered by 40 C.F.R. Parts 5 and 7. See instructions on reverse side.)

IV. List all civil rights lawsuits and admi nistrative complaints decided against the applicant/recipient within the last year t hat allege discrimination based on race, color, national origin, sex, age, or disability and enclose a copy of all decisions. Please desc ribe all corrective action taken. (Do not include employment complaints not covered by 40 C.F.R. Parts 5 and 7. See instructions on reverse side .)

V. List all civil rights compliance reviews of the applicant/reci pient conducted by any agency within the last two years and enc lose a copy of the review and any decisions, orders, or agreem ents based on the review. Please describe any corrective ac tion taken. (40 C.F.R. § 7.80(c)(3))

VI. Is the applicant requesting EPA assistance for ne w construction? If no, proceed to VII; if yes, answer (a) and/o r (b) below.

a. If the grant is for new construction, will all new facilitie s or alterations to existing fa cilities be designed and construc ted to be readily accessible to and usable by persons with disabilities? If yes, proceed to VII; if no, proceed to VI(b). b. If the grant is for new construction a nd the new facilities or alterations to existing facilities will not be readily access ible to and usable by persons with disabilities, explain how a regulatory exception (40 C.F.R. § 7.70) applies.

VII. Does the applicant/recipient provide initial and continuing notice that it does not discriminate on th e basis of race, co lor, national origin, sex, age, or disability in its programs or ac tivities? (40 C.F.R. § 5.140 and § 7.95)

a. Do the methods of notice accommodate thos e with impaired vision or hearing? b. Is the notice posted in a prominent place in the applicant’s offices or facilities or, for education programs and activities , in appropriate periodicals and other written communications? c. Does the notice identify a design ated civil rights coordinator?

VIII. Does the applicant/recipient maintain demographic data on the race , color, national origin, sex, age, or handicap of the population it serves? (40 C.F.R. § 7.85(a))

IX. Does the applicant/recipient have a policy/procedure for pr oviding access to services for pe rsons with limited English pro ficiency? (40 C.F.R. Part 7, E.O. 13166)

X. If the applicant/recipient is an education program or activity , or has 15 or more employees, has it designated an employee to coordinate its compliance with 40 C.F.R. Parts 5 and 7? Provide the name, title, position, mailing address, e-mail address, fax number, and t elephone

number of the designated coordinator.

XI

. If the applicant/recipient is an education program or activity , or has 15 or more employees, has it adopted grievance proce dures that assure the prompt and fair resolution of complaints that allege a viola tion of 40 C.F.R. Parts 5 and 7? Provide a legal citation or I nternet address for, or a copy of, the procedures.

For the Applicant/Recipient

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 statemen t may be punishable by fine or im prisonment or both under applicable la w. I assure that I will ful ly comply with all applicable civil rights stat utes and EPA regulations.

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

For the U.S. Environmental Protection Agency

I have reviewed the information provided by the applicant/recipient and hereby certify that the applicant/recipient has submitt ed all preaward compliance information required by 40 C.F.R. Parts 5 and 7; th at based on the information submitted, this application satisfies the preaward provisions
of 40 C.F.R. Parts 5 and 7; and that the a pplicant has given assurance that it will fully comply with all applicable civil righ ts statutes and EPA regulations.

A. Signature of Authorized EPA Official

See * note on reverse side

. B. Title of Authorized EPA Official C. Date

EPA Form 4700-4 (Rev. 0 4 /20 09 ). Previous editions are obsolete. U.S. ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460

### Instructions for EPA FORM 4700-4 (Rev. 0 4 /2009)

General

Recipients of Federal financial assistance from the U.S. Environmental Protection Agency must comply with the following statutes and regulations.

Title VI of the Civil Rights Acts of 1964 provides that no person in the United States shall, on the gr ounds of race, colo r, 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 statute shall not be constr ued to authorize action with respect to any employment practice of any employer, employment agency, or labor organization (except where the pr imary 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 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 individual with a disability in the United States shall solely by reason of disability be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Fe deral financial assistance. Employment discrimination on the basis of disability 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 fro m participation under any program or activity receiving Federal fina ncial assistance. Employment discrimination is not covered. Age discrimination in employment is prohibited by the Age Discrimination in Employment Act administered by the Equal Empl oyment Opportunity Commission.

Title IX of the Educat ion Amendments of 1972 provides that no person in the United States on the ba sis of sex shall be excluded from participation in, be denied the be nefits of, or be subjected to discrimination under any educati on program or activity receiving Federal financial assistance. Empl oyment 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 institution.

40 C.F.R. Part 5 implements Title IX of the Education Amendments

of 1972.

40 C.F.R. Part 7 implements Title VI of th e Civil Rights Act of 1964,

Section 13 of the 1972 Amendments to the Federal Water Pollution
Control Act, and Section 504 of The Rehabilitation Act of 1973.

The Executive Order 13166 (E.O. 13166) entitled; "Improving

Access to Services for Persons w ith Limited English Proficiency" requires Federal agencies work to ensure that recipients of Federal financial assistance provide me aningful access to their LEP applicants and beneficiaries. 

### Items

“Applicant” means any entity that files an application or unsolicited proposal or otherwise requests EPA a ssistance. 40 C.F.R. §§ 5.105,

7.25.

“Recipient” means any entity, other than applicant, which will actually

receive EPA assistance. 40 C.F.R. §§ 5.105, 7.25.

“Civil rights lawsuits and administrative complaints” means any lawsuit or administrative complaint alleging discrimination on the basis of race, color, national origin, sex, age, or disability pending or decided against the applicant and/or entity which actually benefits from the grant, but excluding employment complaints not covered by 40 C.F.R. Parts 5 and 7. For example, if a city is the named applicant but the grant will actually benefi t the Department of Sewage, civil rights lawsuits involving both the ci ty and the Department of Sewage

should be listed.

“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, co lor, national origin, sex, age, or disability.

Submit this form with the original an d 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 item is not relevant to the project for which assistance is requested, write “NA” for “Not Applicable.”

In the event applicant is uncertain about how to answ er any questions, EPA program officials should be contacted for clarification.

* Note: Signature appears in the Approval Section of the EPA Comprehensive Administrative Re view For Grants/Cooperative Agreements & Continuation/Su pplemental Awards form.

Approval indicates, in the reviewer’s opinion, questions I – VI of Form 4700-4 comply with the preaward administrative requirements for EPA

assistance.

“Burden Disclosure Statement”

EPA estimates public reporting burden for the preparation of this form to average 30 minutes per response. This estimate includes the time for reviewing instructions, gatheri ng and maintaining the data needed and completing and reviewing the form. Send comments regarding the burden estimate, including suggestions for reducing this burden, to U.S. EPA, Attn: Collection Strategi es Division (MC 2822T), Office of Information Collection, 1200 Pennsy lvania Ave., NW, Washington,
D.C. 20460; and to the Office of In formation and Regulatory Affairs, Office of Management and B udget, Washington, D.C. 20503.

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 the above statutes and regulations.