Form MO780-2530 "Clean Water State Revolving Fund Green Project Reserve" - Missouri

Form MO780-2530 is a Missouri Department of Natural Resources form also known as the "Form Mo780-2530 "clean Water State Revolving Fund Green Project Reserve" - Missouri". The latest edition of the form was released in January 1, 2015 and is available for digital filing.

Download a PDF version of the Form MO780-2530 down below or find it on Missouri Department of Natural Resources Forms website.

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Download Form MO780-2530 "Clean Water State Revolving Fund Green Project Reserve" - Missouri

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FOR OFFICE USE ONLY
MISSOURI DEPARTMENT OF NATURAL RESOURCES
WATER PROTECTION PROGRAM, FINANCIAL ASSISTANCE CENTER
PROJECT NUMBER
CLEAN WATER STATE REVOLVING FUND
GREEN PROJECT RESERVE
DATE RECEIVED
NOTE ► Submit only if the proposed project includes Green Project Reserve components.
1.0 APPLICANT INFORMATION
NAME OF PROJECT
NAME OF APPLICANT
TELEPHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
2.0 GREEN INFRASTRUCTURE
DEFINITION
Green stormwater infrastructure includes a wide array of practices at multiple scales that manage wet weather and maintains and
restores natural hydrology by infiltrating, evapotranspiring and harvesting and using stormwater. On a regional scale, green
infrastructure is the preservation and restoration of natural landscape features, such as forests, floodplains and wetlands, coupled with
policies such as infill and redevelopment that reduce overall imperviousness in a watershed. On the local scale, green infrastructure
consists of site- and neighborhood-specific practices, such as bioretention, trees, green roofs, permeable pavements, and cisterns.
2.1 CATEGORICAL PROJECTS (CHECK ALL THAT MAY APPLY)
Green streets.
Restoration of permanent natural features.
Wet weather managements systems for parking areas.
Management of wetlands.
Street tree or urban forestry program.
Preservation of hydrologic processes.
Downspout disconnection.
Acquisition of land or easements benefitting water quality.
Retrofit program to keep wet weather out of sewers.
2.2 CATEGORICAL PROJECT SUMMARY (ATTACH SUPPORTING DOCUMENTATION)
2.3 ESTIMATED CATEGORICAL GREEN PROJECT RESERVE AMOUNT
$
2.4 BUSINESS CASE PROJECTS (CHECK ALL THAT MAY APPLY)
Projects designed to mimic the natural hydrologic conditions of the site or watershed.
Projects that capture, treat, infiltrate, or evapotranspire water on the parcels where it falls and does not result in interbasin transfers
of water.
Projects in lieu of or to supplement municipal hard/gray infrastructure.
Projects considering both landscape and site scale to protect water quality.
2.5 BUSINESS CASE NARRATIVE (ATTACH SUPPORTING DOCUMENTATION)
2.6 ESTIMATED BUSINESS CASE GREEN PROJECT RESERVE AMOUNT
$
MO 780-2530 (01-15)
Page 1
FOR OFFICE USE ONLY
MISSOURI DEPARTMENT OF NATURAL RESOURCES
WATER PROTECTION PROGRAM, FINANCIAL ASSISTANCE CENTER
PROJECT NUMBER
CLEAN WATER STATE REVOLVING FUND
GREEN PROJECT RESERVE
DATE RECEIVED
NOTE ► Submit only if the proposed project includes Green Project Reserve components.
1.0 APPLICANT INFORMATION
NAME OF PROJECT
NAME OF APPLICANT
TELEPHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
2.0 GREEN INFRASTRUCTURE
DEFINITION
Green stormwater infrastructure includes a wide array of practices at multiple scales that manage wet weather and maintains and
restores natural hydrology by infiltrating, evapotranspiring and harvesting and using stormwater. On a regional scale, green
infrastructure is the preservation and restoration of natural landscape features, such as forests, floodplains and wetlands, coupled with
policies such as infill and redevelopment that reduce overall imperviousness in a watershed. On the local scale, green infrastructure
consists of site- and neighborhood-specific practices, such as bioretention, trees, green roofs, permeable pavements, and cisterns.
2.1 CATEGORICAL PROJECTS (CHECK ALL THAT MAY APPLY)
Green streets.
Restoration of permanent natural features.
Wet weather managements systems for parking areas.
Management of wetlands.
Street tree or urban forestry program.
Preservation of hydrologic processes.
Downspout disconnection.
Acquisition of land or easements benefitting water quality.
Retrofit program to keep wet weather out of sewers.
2.2 CATEGORICAL PROJECT SUMMARY (ATTACH SUPPORTING DOCUMENTATION)
2.3 ESTIMATED CATEGORICAL GREEN PROJECT RESERVE AMOUNT
$
2.4 BUSINESS CASE PROJECTS (CHECK ALL THAT MAY APPLY)
Projects designed to mimic the natural hydrologic conditions of the site or watershed.
Projects that capture, treat, infiltrate, or evapotranspire water on the parcels where it falls and does not result in interbasin transfers
of water.
Projects in lieu of or to supplement municipal hard/gray infrastructure.
Projects considering both landscape and site scale to protect water quality.
2.5 BUSINESS CASE NARRATIVE (ATTACH SUPPORTING DOCUMENTATION)
2.6 ESTIMATED BUSINESS CASE GREEN PROJECT RESERVE AMOUNT
$
MO 780-2530 (01-15)
Page 1
3.0 WATER EFFICIENCY
DEFINITION
The use of improved technologies and practices to deliver equal or better services with less water. Water efficiency encompasses
conservation and reuse efforts, as well as water loss reduction and prevention, to protect water resources for the future.
3.1 CATEGORICAL PROJECTS (CHECK ALL THAT MAY APPLY)
Installing or retrofitting water efficient devices.
Installing water meters in unmetered areas.
Replacing existing broken/malfunctioning water meters, or upgrading existing meters, with:
Automatic meter reading (AMR) systems;
Meters with built in leak detection; and/or
Backflow prevention devices installed in conjunction with water meter replacement.
Retrofitting/adding AMR capabilities or leak detection equipment to existing meters (not replacing the meter itself).
Water audit and water conservation plans, which are reasonably expected to result in a capital project.
Recycling and water reuse projects that replace potable sources with non-potable sources.
Retrofit or replacement of existing landscape irrigation systems with more efficient landscape irrigation systems, including moisture
and rain sensing equipment.
Retrofit or replacement of existing agricultural irrigation system with more efficient agricultural irrigation systems.
3.2 CATEGORICAL PROJECT SUMMARY (ATTACH SUPPORTING DOCUMENTATION)
3.3 ESTIMATED CATEGORICAL GREEN PROJECT RESERVE AMOUNT
$
3.4 BUSINESS CASE PROJECTS (CHECK ALL THAT MAY APPLY)
Projects utilizing water saving elements or reducing water consumption.
Projects delivering equal or better services with less net water use as compared to traditional or standard technologies and
practices.
Projects with efficient water use thereby creating an energy and financial savings.
3.5 BUSINESS CASE NARRATIVE (ATTACH SUPPORTING DOCUMENTATION)
3.6 ESTIMATED ANNUAL COST SAVINGS
3.7 ESTIMATED ANNUAL WATER SAVINGS
$
per year
gallons / year
3.8 ESTIMATED BUSINESS CASE GREEN PROJECT RESERVE AMOUNT
$
MO 780-2530 (01-15)
Page 2
4.0 ENERGY EFFICIENCY
DEFINITION
The use of improved technologies and practices to reduce the energy consumption of water quality projects, use energy in a more
efficient way, and/or produce/utilize renewable energy.
4.1 CATEGORICAL PROJECTS (CHECK ALL THAT MAY APPLY)
Renewable energy projects such as wind, solar, geothermal, micro-hydroelectric, and biogas combined head and power systems
that provide power to a publicly owned treatment works (POTW).
Achieving a 20 percent reduction in energy consumption.
Collection system infiltration and inflow (I/I) detection equipment.
POTW energy management planning, including energy assessments, energy audits, optimization studies, and sub-metering of
individual processes to determine high energy use areas, which are reasonably expected to result in a capital project.
4.2 CATEGORICAL PROJECT SUMMARY (ATTACH SUPPORTING DOCUMENTATION)
4.3 ESTIMATED CATEGORICAL GREEN PROJECT RESERVE AMOUNT
$
4.4 BUSINESS CASE PROJECTS (CHECK ALL THAT MAY APPLY)
Projects that are cost effective and presented by an evaluation identifying the energy savings and payback on capital and operation
and maintenance costs that does not exceed the useful life of the asset.
Projects maximizing on energy saving opportunities for the POTW or unit process.
Projects utilizing tools such as the Environmental Protection Agency (EPA) Energy Star’s Portfolio Manager or EPA Check Up
Program for Small Systems to document current energy usage and track anticipated savings.
4.5 BUSINESS CASE NARRATIVE (ATTACH SUPPORTING DOCUMENTATION)
4.6 EXISTING PUMP/MOTOR EFFICIENCY RATING (IF APPLICABLE)
4.7 NEW PUMP/MOTOR EFFICIENCY RATING (IF APPLICABLE)
%
%
4.8 ESTIMATED ANNUAL COST SAVINGS
4.9 ESTIMATED ANNUAL ELECTRIC SAVINGS
$
per year
kilowatt / year
4.10 ESTIMATED BUSINESS CASE GREEN PROJECT RESERVE AMOUNT
$
MO 780-2530 (01-15)
Page 3
5.0 ENVIRONMENTALLY INNOVATIVE
DEFINITION
Environmentally innovative projects include those that demonstrate new and/or innovative approaches to delivering services or
managing water resources in a more sustainable way.
5.1 CATEGORICAL PROJECTS (CHECK ALL THAT MAY APPLY)
Total/integrated water resources management planning likely to result in a capital project.
Utility sustainability plan consistent with the EPA State Revolving Fund’s sustainability policy.
Greenhouse gas inventory or mitigation plan and submission to a registry (such as Climate Leaders or Climate Registry).
Planning activities by a POTW to prepare for adaptation to the long-term effects of climate change and/or extreme weather.
Construction of US Building Council Leadership in Energy and Environmental Design (LEED) certified buildings or renovation or an
existing building on POTW facilities.
Decentralized wastewater treatment solutions to existing deficient or failing onsite wastewater systems.
5.2 CATEGORICAL PROJECT SUMMARY (ATTACH SUPPORTING DOCUMENTATION)
5.3 ESTIMATED CATEGORICAL GREEN PROJECT RESERVE AMOUNT
$
5.4 BUSINESS CASE PROJECTS (CHECK ALL THAT MAY APPLY)
Innovative technology or process whose performance is expected to address water quality, but the actual performance has not
been demonstrated in Missouri.
Technology or process that is not widely used in Missouri, but does perform as well or better than conventional technology or
process at a lower cost.
Conventional technology or process that is used in a new application in Missouri.
5.5 BUSINESS CASE NARRATIVE (ATTACH SUPPORTING DOCUMENTATION)
5.6 ESTIMATED BUSINESS CASE GREEN PROJECT RESERVE AMOUNT
$
6.0 CERTIFICATION
I certify that I am familiar with the information contained in this application and to the best of my knowledge and belief such information
is true, complete and accurate. I agree if funding is awarded, to comply with all applicable terms, conditions and procedures of the
Missouri Department of Natural Resources, the applicable rules and regulations of the Missouri Clean Water Commission and the terms
and conditions of the loan agreement.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
PRINTED NAME
DATE
TITLE
TELEPHONE NUMBER WITH AREA CODE
EMAIL ADDRESS
Mail completed copy to:
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FINANCIAL ASSISTANCE CENTER
P.O. BOX 176
JEFFERSON CITY, MO 65102-0176
MO 780-2530 (01-15)
Page 4
INSTRUCTIONS FOR COMPLETING
CLEAN WATER STATE REVOLVING FUND
GREEN PROJECT RESERVE
Any funding assistance is subject to all State Revolving Fund requirements. Potential applicants should contact the Missouri
Department of Natural Resources’ Financial Assistance Center prior to completing and submitting an application. Contact the Financial
Assistance Center at 573-751-1192 or toll free at 800-361-4827 or visit online at
dnr.mo.gov/env/wpp/srf/index.html
for more
information.
The Green Project Reserve (GPR) became a provision of the Clean Water State Revolving Fund program in 2009 as a result of the
American Recovery and Reinvestment Act. Certain federal capitalization grants, since 2009, have included language relating to the
establishment of the GPR and to specify a targeted percentage of funds for GPR projects or components of projects (to the extent
applications are received). The U.S. Environmental Protection Agency has developed guidance that describes the federal requirements
for GPR. Visit EPA’s website for the current available information at water.epa.gov/grants_funding/cwsrf/Green-Project-Reserve.cfm.
The department also has a webpage dedicated to the GPR information available at dnr.mo.gov/env/wpp/srf/gpr.htm.
GPR projects are divided into four categories: green infrastructure, water efficiency, energy efficiency, or environmentally innovative.
The EPA has identified project elements which are considered “categorically green” for each of the four categories. For project
elements not specifically identified as “categorically green,” a business case needs to be developed.
Business Case Development
A business case is a due diligence document which demonstrates that the project element(s) meets the GPR criteria.
Length of a business case:
Business cases should be adequate but not exhaustive. There is no specific format or approach required.
Limit the information contained in the business case to only the pertinent “green” information needed to justify the project,
which may include a detailed analysis and/or calculations.
A business case can simply summarize results from, and then cite, existing documentation such as facility plans, water or
energy audits, results of a sanitary sewer evaluation study (SSES), etc.
Content of a business case:
Business cases must address the decision criteria for the category of project.
Quantifiable water and/or energy savings or water loss reduction and energy efficiency projects should be included.
The cost and financial benefit of the project should be included, along with the payback time period, where applicable.
Items which strengthen business case, but are not required:
Showing that the project was designed to enable equipment to operate most efficiently.
Demonstrating that equipment will meet or exceed standards set by professional associations.
Including operator training or committing to utilizing existing tools such as the EPA Energy Star’s Portfolio Manager
(www.energystar.gov/) or EPA Check Up Program for Small Systems (CUPSS)
(water.epa.gov/infrastructure/drinkingwater/pws/cupss/index.cfm) for energy efficiency projects.
Example business cases are available at:
EPA’s GPR website: water.epa.gov/grants_funding/cwsrf/Green-Project-Reserve.cfm.
Department’s GPR webpage: dnr.mo.gov/env/wpp/srf/gpr.htm.
1.0
Complete the applicant information. Include the name of the project, name of the applicant entity and contact information.
2.0
Complete the green infrastructure section, if applicable.
Projects that do not meet the definition of green infrastructure include:
A.
Stormwater controls that have impervious or semi-impervious liners and provide no compensatory evapotranspirative or
harvesting function for stormwater retention.
B.
Stormwater ponds that serve an extended detention function and/or extended filtration. This includes soil lined detention
basins.
C. In-line and end-of-pipe treatment systems that only filter or detain stormwater.
D. Underground stormwater control and treatment devices such as swirl concentrators, hydrodynamic separators, baffle
systems for grit, trash removal/floatables, oil and grease, inflatable booms and dams for in-line underground storage and
diversion of flows.
E.
Stormwater conveyance systems that are not soil/vegetation based (swales) such as pipes and concrete channels.
F.
Hardening, channelizing, or straightening streams and/or stream banks.
G. Street sweepers, sewer cleaners, and vactor trucks unless they support green infrastructure projects.
2.1
Check all of the applicable boxes which correspond to the categorically green infrastructure components of the proposed
project.
2.2
Briefly describe the green infrastructure categorical components of the proposed project. Attach supporting documentation as
needed.
2.3
Provide the estimated green infrastructure categorical total capital cost of the proposed project.
2.4
Check all of the applicable boxes which can be considered for a green infrastructure business case.
Examples of projects requiring a green infrastructure business case are as follows:
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