Household Hazardous Waste Grant Application Indiana Household Hazardous Waste Grant Program {51899}

HOUSEHOLD HAZARDOUS WASTE GRANT APPLICATION INDIANA HOUSEHOLD HAZARDOUS WASTE GRANT PROGRAM State Form 51899 (8-04) Office of Pollution Prevention and Technical Assistance HHW GRANT PROGRAM 402 West Washington Street, W041 P.O. Box 7095 Indianapolis, IN 46207-7095 Internet: http://www.in.gov/idem/oppta/recycling/grants/ Indiana Department of Environmental Management INSTRUCTIONS: Pre-applications are required. For assistance call your regional grant representative at the Office of Pollution Prevention and Technical Assistance, Source Reduction and Recycling Branch (800-988-7901). Please print or type. SECTION 1 Program administrator (contact person) Mr. Ms. Title: Official name of agency or organization: Federal ID Number: Address: City: SECTION 2 PROJECT SUMMARY Please shade area served or attach map showing area to be served. ZIP Code + 4: Phone: Fax: E-Mail: County (ies): APPLICANT INFORMATION SECTION 3 Target number of households: If school, target number of students: Total project cost: SECTION 4 (Check the appropriate box) Joint application; attach participant list School (K-12) County City SECTION 5 SWMD 12/31 cash balance: $ $ GRANT DATA Target population: Tons of material to be diverted through project: Funds requested: TYPE OF APPLICANT Solid Waste Management District University Non-profit Town SOLID WASTE MANAGEMENT DISTRICTS ONLY $ Report the cash balance as reported on State Board of Accounts, Form # SWMDAR-1, Part 1, Column F, Solid Waste Management Fund. SECTION 6 SIGNATURE I certify that submission of this application has been duly authorized by the governing body of the entity and that I am legally authorized by the governing body to sign the application. Signature of applicant Printed name Date (month, day, year) American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS: Round amounts up to whole dollars. A dollar for dollar cash match is required for disposal cost and equipment purchases. If grant is awarded, an approved budget page will be included in Exhibit A of the grant agreement. SECTION 7 PROPOSED BUDGET Grant Request Personnel $ $ $ $ $ $ $ $ $ $ $ $ Cash Match In-Kind Total Project/Equipment Costs $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Operating/Program Costs $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Contractor/Professional Fees $ $ $ $ $ $ $ $ $ $ $ $ Education/Promotion Costs $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Enter column totals in boxes below. $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS: Applications are evaluated based on the responses to the questions listed in numbers 1-4. Each response must be complete and numbered; please attach the application question responses to the cover page, proposed budget, and any other applicable materials being submitted. SECTION 8 1) Program Description a) b) Describe the proposed project and partners involved. Describe the goals and objectives of the program. i) ii) iii) Is this application for a new HHW program? What materials will be collected through the program? How much waste do you expect this program to divert from improper disposal? (1) (2) iv) v) c) Justify diversion projections in terms of increased participation and collection, etc. Explain any assumptions made in your calculations. APPLICATION QUESTIONS What area and population will the program serve? Provide participation estimates, and explain assumptions made in the calculations. Is this application for an expanded HHW program? i) ii) What materials are currently being collected through the program? What new materials will be collected as a result of the expansion? d) e) Please provide the location(s) of facility or events, operating hours and collection schedule. Demonstrate the benefits of waste diversion specific to your area (safety, benefits to ground water and wastewater treatment facilities, etc.). i) Explain how project achieves decreased toxicity or increased benefit to the environment. f) g) Provide anticipated project plan timeline (e.g., activity occurs months 1-3, months 4-6, months 7-9, etc.). Provide locations (addresses) of grant funded equipment already owned by your organization, recycling drop-off sites, and household hazardous waste collection sites or facilities in your area, plus hours of operation. 2) Waste Management a) How will this project divert waste from improper disposal? (For HHW projects, the focus should be on the proper disposal of HHW and increased participation.) Provide material flow plan (e.g., amount and types of materials collected, processed and final end disposal). i) ii) Indicate which tasks program staff will perform and which the contractor will perform. Where will the materials be stored? (1) iii) iv) v) vi) Does storage meet building and fire code standards? b) How will materials be collected? How will materials be packaged for shipping? Is the HHW packaged for shipping by program staff or the contractor? What, if any, materials will be offered for reuse? (1) (2) How will they be evaluated? Who will have access to the reusable materials? c) Provide the company name, address, phone and contact person for your contractor(s). i) Please provide IDEM with your contractor's current disposal/recycling price list. d) What is the method of final disposal used for each material collected: incineration, treatment, or recycling? i) How will you ensure materials are recycled or properly disposed? e) Please attach safety plan and plan for employee training. American LegalNet, Inc. www.FormsWorkflow.com 3) Education Plan a) Describe your education plan. i) ii) iii) Describe the goals of your education and/or promotion plan. What will be the education and promotion content or message? Describe project's source reduction component. This is very important for HHW projects. Please describe your educational activities to reduce the need for HHW disposal. Estimate the public/school education impact numbers. Describe type of education methods employed. Describe media used and how the target audience will be informed about proper participation. iv) v) vi) 4) Project Sustainability a) Explain all budget page line items (grant requests, cash, and in-kind matching columns). Quotes and spec sheets are required for all purchases. If you are proposing to purchase or trade-in used equipment, three appraisals of the equipment must be submitted. Summary of personnel investment to include number of hours and a detailed work plan (new and current resources). Sustained funding plan for con