FORMApprovec3MB:No.2030-0020Expires04-30-2012PreawardComplianceReviewReportforAllApplicantsandRecipientsRequestingEPAFinancialAssistanceNote:Readinstructionsoilothersidebeforecompletingform.I.Applicant/Recipient(Name,Address,State,ZipCode)..DONSNo.DepartmentofPesticideRegulation,10011St.,Sacramento,CA.,95812-40158032.1891II.IstheapplicantcurrentlyreceivingEPAassistance?YesIII.Listallcivilrightslawsuitsandadministrativecomplaintspendingagainsttheapplicant/recipientthatallegediscriminationbasedonrace,color,nationalorigin,sex,age,ordisability.(Donotincludeemploymentcomplaints.notcoveredby40C.F.R.Parts5and7.Seeinstructionsonreverseside.)NoneIV.Listallcivilrightslawsuitsandadministrativecomplaintsdecidedagainsttheapplicant/recipientwithinthelastyearthatallegediscriminationbasedonrace,color,nationalorigin,sex,age,ordisabilityandencloseacopyofalldecisions.Pleasedescribeallcorrectiveactiontaken.(Doriotincludeemploymentcomplaintsnotcoveredby40C.F.R.Parts5and7.Seeinstructionsonreverseside.)NoneListallcivilrightscompliancereviewsoftheapplicant/recipientconductedbyanyagencywithinthelasttwoyearsandencloseacopyofthereviewandanydecisions,orders,oragreementsbasedonthereview.Pleasedescribeanycorrectiveactiontaken.(40C.F.R.§7.80(c)(3))NoneVI.IstheapplicantrequestingEPAassistancnowconstruction?Ifno,proceedtoVII;ifyes,answer(a)and/or(b)below.YesNoIfthegrantisfornewconstruction,willallnewfacesoralterationstoexistingfacilitiesbedesignedandconstructedtobereadilyaccessibletoandusablebypersonswithdisabilities?Ifyes,proceedtoVII;ifno,proceedtoVI(b).Yeslob.Ifthegrantisfornewconstruction.andthenewfacilitiesoralterationstoexistingfacilitieswjllnotbereadilyaccessibletoandusablebypersonswithdisabilities,explainhowaregulatoryexception(40C.F.R.§7.70)applies.zenNoVIL*Doestheapplicant/recipientprovideinitialandcontinuingnoticethatitdoesnotdiscriminateonthebasisofrace,color,nationalorigin,sex,age,ordisabilityinitsprogramsoractivities?(40C.F,R.§5.140and§7,95)Noa,Dothemethodsofnoticeaccommodatethosewithimpairedvisionorhearing?YesNoIsthenoticepostedinaprominentplaceintheapplicant’soffifacilitiesor,foreducationpromsandactivities,inappropriatcperiodicalsandotherwrittencommunications?YesNoc.Doesthenoticeidentifyadesignatedcivilrightscooinator?‘YesVIII.*Doestheapplicant/recipientmaintaindemographicdataontherace,color,nationalorigin,sex,age,orhandicapofthepopulationitserves?(40C.F,R.§7.55(a))NoIX.*Doestheapplicant/recipienthaveapolicy/procedureforprovidingaccesstoservicesforpersonswithlimitedEnglishproficiency?(40C.F.R,Part7,EQ.13166)YesX.*Iftheapplicant/recipientisaneducationprogramoractivity,orhas15ormoreemployees,hasitdesignatedanemployeetocoordinateitsompliancewith40C.F.R.Parts5and7?Providethename,title,position,mailingaddress,e-mailaddress,faxnumber,andtelephonenumberofthedesignatedcoordinator.Yes(SeeAttached)X1’Iftheapplicant/recipientisaneducationprogramoractivity,orhas15ormoreemployees,hasitadoptedgrievanceproceduresthatassurethepromptandfairresolutionofcomplaintsthatallegeaviolationof40C.F.R.Parts5and7?ProvidealegalcitationorInternetaddressfor,oracopyof,theprocedures.YesFortheApplicant/RecipientIcertifythatthestatementsIhavemadeonthisformandallattachmentstheretoaretrue,accurateandcomplete.IacknowledgethatanyknowinglyfalseormisleadingstatementmaybepunishablebyfineorimprisonmentorbothunderappLicablelaw.IassurethatIwillfullycomplywithallapplicablecivilrightsstautsandEPAregulations.ofAuthorizedOfficialC.Dirctor IFortheU.S.EnvironmentalProtectionAgencyIhavere’viewedtheinformationprovidedbytheapplicant/recipientandherebycertifythattheapplicant/recipienthassubmittedallpreawardcomplianceinformationrequiredby40C,F.R.Parts5and7;thatbasedontheinformationsubmitted,thisapplicationsatisfiesthepreawardprovisionsof40C.F.R.Parts5and7;andthattheapplicanthasgivenassurancethatitwillfullycomplywithallapplicablecivilrightsstatutesandEPAregulations.A.SignatureofAuthorizedEPAOfficialB.TitleofAuthorizedEPAOfficialC.Date.nntnnwvprp-—EPAForm4700-4(Rev.04/2009).PreviouseditiousareobsoleteMAY2020102. i6S1..-

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