State Form 53432 "Indiana Clean Vessel Act Grant Application" - Indiana

Form State53432 or the "Indiana Clean Vessel Act Grant Application" is a form issued by the Indiana Department of Environmental Management.

The form was last revised in November 1, 2018 and is available for digital filing. Download an up-to-date Form State53432 in PDF-format down below or look it up on the Indiana Department of Environmental Management Forms website.

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INDIANA CLEAN VESSEL ACT
Office of Program Support
100 North Senate Avenue, IGCN 1316
GRANT APPLICATION
Indianapolis, IN 46204-2251
State Form 53432 (R6 / 11-18)
Telephone: (800) 988-7901
Indiana Department of Environmental Management
E-mail:
BoatingGrants@idem.in.gov
To be considered for funds allocated to Indiana under the Clean Vessel Act, complete
For Office Use Only
and mail or e-mail this form to the above address. Instructions and additional
Date Received (month, day, year)
CVA Grant Number
information, including grant requirements, are available at
www.idem.IN.gov/prevention/. Attach additional sheets as needed.
I. Applicant Information
Marina / Entity (Legal Business Name)
Owner Name
Telephone Number
E-Mail
Mailing Address (number and street)
City
ZIP Code
Operator Name
Telephone Number
E-Mail
Employer Identification Number (Federal EIN)
Data Universal Numbering System (DUNS) Number
II. Site Location and Ownership Information
Site Address (number and street)
City
County
Township
Waterbody
River Mile
GPS Coordinates (Decimal)
Latitude:
Longitude:
Approximate number of recreational
Approximate number of recreational
Approximate number of
boats with holding tanks:
boats with portapotties:
boats that are live-aboards:
Are any areas or amenities of this facility unavailable to
☐ Yes ☐ No If Yes, please describe:
the general public?
Does the slip/moorage rental contract contain language
prohibiting discharge of boat sewage into facility
☐ Yes ☐ No, but it will be added for the season beginning 20
.
waterways?
Is this site a Certified Clean Marina? (Clean Marina
☐ Yes ☐ No
members receive priority for CVA Grant funds.)
Please check which of the following wastewater disposal services are currently available at this location:
☐ Pumpout Station
☐ Portable Dump Station
☐ Portable Pumpout
☐ Other, please describe:
III. Project Plan
Type of Proposed Service:
Location of Proposed Service:
Nearest Existing
Estimated Number
Will a fee be charged?
Similar Service:
of Boats to be
☐ Stationary Pumpout
☐ Fuel Dock
☐ Free
Served by Project
☐ Portable Dump Station
☐ Existing Docks
☐ $
Per Year:
miles
☐ Portable Pumpout
☐ New Docks
(Max. $5.00/use)
☐ Other
☐ Other
Proposed service will discharge to:
☐ On-Site Holding Tank which will be emptied by a licensed septic hauler for disposal by an approved treatment facility.
(Submit evidence, in writing, of a contract with a licensed septic hauler, as well as approval from the local health official.)
☐ Public Wastewater Treatment Facility (Submit evidence, in writing, of consent from owner of the system.)
☐ On-Site Septic System (Submit evidence, in writing, of approval from local health officials, stating that sufficient sewage
disposal capacity is available.)
How will boaters continually be
educated about the availability of the
new service and how to use it properly?
Page 1 of 2
Reset Form
INDIANA CLEAN VESSEL ACT
Office of Program Support
100 North Senate Avenue, IGCN 1316
GRANT APPLICATION
Indianapolis, IN 46204-2251
State Form 53432 (R6 / 11-18)
Telephone: (800) 988-7901
Indiana Department of Environmental Management
E-mail:
BoatingGrants@idem.in.gov
To be considered for funds allocated to Indiana under the Clean Vessel Act, complete
For Office Use Only
and mail or e-mail this form to the above address. Instructions and additional
Date Received (month, day, year)
CVA Grant Number
information, including grant requirements, are available at
www.idem.IN.gov/prevention/. Attach additional sheets as needed.
I. Applicant Information
Marina / Entity (Legal Business Name)
Owner Name
Telephone Number
E-Mail
Mailing Address (number and street)
City
ZIP Code
Operator Name
Telephone Number
E-Mail
Employer Identification Number (Federal EIN)
Data Universal Numbering System (DUNS) Number
II. Site Location and Ownership Information
Site Address (number and street)
City
County
Township
Waterbody
River Mile
GPS Coordinates (Decimal)
Latitude:
Longitude:
Approximate number of recreational
Approximate number of recreational
Approximate number of
boats with holding tanks:
boats with portapotties:
boats that are live-aboards:
Are any areas or amenities of this facility unavailable to
☐ Yes ☐ No If Yes, please describe:
the general public?
Does the slip/moorage rental contract contain language
prohibiting discharge of boat sewage into facility
☐ Yes ☐ No, but it will be added for the season beginning 20
.
waterways?
Is this site a Certified Clean Marina? (Clean Marina
☐ Yes ☐ No
members receive priority for CVA Grant funds.)
Please check which of the following wastewater disposal services are currently available at this location:
☐ Pumpout Station
☐ Portable Dump Station
☐ Portable Pumpout
☐ Other, please describe:
III. Project Plan
Type of Proposed Service:
Location of Proposed Service:
Nearest Existing
Estimated Number
Will a fee be charged?
Similar Service:
of Boats to be
☐ Stationary Pumpout
☐ Fuel Dock
☐ Free
Served by Project
☐ Portable Dump Station
☐ Existing Docks
☐ $
Per Year:
miles
☐ Portable Pumpout
☐ New Docks
(Max. $5.00/use)
☐ Other
☐ Other
Proposed service will discharge to:
☐ On-Site Holding Tank which will be emptied by a licensed septic hauler for disposal by an approved treatment facility.
(Submit evidence, in writing, of a contract with a licensed septic hauler, as well as approval from the local health official.)
☐ Public Wastewater Treatment Facility (Submit evidence, in writing, of consent from owner of the system.)
☐ On-Site Septic System (Submit evidence, in writing, of approval from local health officials, stating that sufficient sewage
disposal capacity is available.)
How will boaters continually be
educated about the availability of the
new service and how to use it properly?
Page 1 of 2
When will the proposed service be available to boaters?
☐ January
☐ April
☐ July
☐ October
☐ February
☐ May
☐ August
☐ November
☐ All Year
☐ March
☐ June
☐ September
☐ December
Months
Or, only…
☐ Friday
☐ Saturday
☐ Monday
☐ Wednesday
☐ Daily
☐ Sunday
☐ Tuesday
☐ Thursday
Days
Or, only…
A.M. and
P.M.
☐ 24 Hours
Hours
Or, between…
Project Description - Please explain the proposed project fully, including what will be purchased, what new
facilities will be installed, what existing facilities will be changed, whether dredging will occur, who will be hired to
☐ Attached
accomplish the proposed work, the type of boats that will use the facility, etc.
Two (2) manufacturers or contractors bids for each major component of the project (any item or service over
☐ Attached
$10,000), model numbers of equipment to be purchased. Clearly indicate which is the selected bid.
Photograph of the site where project will be located.
☐ Attached
Project site plan—Showing the layout of the marina and location of the components. (blueprints, drawings, or
☐ Attached
specifications)
IV. Budget
Eligible Costs
Purchase Cost
Installation Cost
Total for Line Item
IMPORTANT: Costs incurred prior to State approval are not eligible for reimbursement.
$
$
Permits
Engineering costs
(Only eligible when performed by a
$
$
registered professional engineer.)
$
$
$
Boat vessel waste collection facility
Utilities (sewer, water, electrical) – to
accommodate the installation and
operation of the waste collection
$
$
$
facility
$
$
$
Sewage lift stations
$
$
$
Sewage holding tanks
Floats, piling, gangways to support
$
$
$
pumpouts/dump stations
Signage (Instructional signage and
$
$
$
symbol as required by the Program)
Educational materials (posters,
$
$
brochures, etc.)
$
Total Eligible Proposed Project Cost - (A)
$
Cash Match
Value of
$
Total Match from Non-Federal Funds - (B)
Labor
Value of
$
$
Materials
Percent Matching Funds (B divided by A)
%
(Applicants must provide at least 25% of the Total Eligible Proposed Project Cost.)
$
Total Grant Funds Requested (A minus B)
V. Applicant Signature
I swear or affirm, under penalty of perjury as specified by IC 35-44.1-2-1 and other penalties specified by IC 13-30-10, that the
statements and representations in this application are true, accurate, and complete.
Owner Signature
Printed Name
Date (month, day, year)
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