2530-FM-BWM0215
Rev. 12/2009
Host Municipality Technical Evaluation Grant
Under Section 510
The Hazardous Sites Cleanup Act, Act 108 of October, 1988
Pennsylvania Department of Environmental Protection
Bureau of Waste Management
P.O. Box 8471
Harrisburg, PA 17105-8471
2530-FM-BWM0215
Rev. 12/2009
ACT 108 HOST MUNICIPAL INDEPENDENT TECHNICAL EVALUATIONS
INSTRUCTIONS
A.
GENERAL INSTRUCTIONS
1.
Each application must be returned to the Regional Office in accordance with the accompanying cover letter.
A completed application consists of:
1. Part I — Applicant Information
2. Part II — The Proposal: Executive Summary and Scope of Work
3. Part Ill — Financial/Work Completion Data
4. Part IV — Supporting Documents
B.
2.
Applications should be bound with a staple at the upper left corner. Other bindings, covers, tabbed pages,
etc. are not necessary. Detach these instructions prior to submittal.
3.
The application will be reviewed for completeness and technical merit.
PART I — APPLICANT INFORMATION*
Complete Part I — Applicant Information Form:
1.
The applicant must be a municipality. (city, township, town, borough, or home rule municipality)
4.
This is the official agency representative who will be contacted concerning details of the application and
agreement development.
6.
This must not exceed $50,000. Refer to the Technical Evaluations Fact Sheet or contact your Regional Office
contact for further assistance in defining approved project costs.
8.
Should your application be approved, it is recommended that the work tasks not be initiated until a grant
agreement has been fully executed. However, should you, at your own risk, be willing to proceed prior to the
full execution of the agreement please check the appropriate block as follows:
A.
Will proceed upon receipt of funding offer.
B.
Will proceed upon receipt of grant agreement.
C.
Will not proceed until agreement is fully executed.
*Numbers correspond to information on Page 4, Part I.
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Rev. 12/2009
PART II — THE PROPOSAL
A.
EXECUTIVE SUMMARY
On one page, identify the municipality applying for the grant, the name of the site being evaluated, the contact
person and telephone number, the total evaluation costs, the contractor proposed to conduct the evaluation and
how they were selected, associated contractor costs, and the total funds requested. Provide a brief description of
the proposed evaluation, identifying in general the scope of the evaluation. State why conducting this technical
evaluation will benefit the municipality.
B.
SCOPE OF WORK
Provide a brief narrative description of the evaluation to be conducted by the municipality covered by the grant
application.
1.
The Scope of Work should be designed to insure that all requirements for conducting the technical evaluation,
as noted in Act 108, Section 510, are met. The Scope of Work should address at a minimum, the tasks and
methodology for assessing and evaluating the remedial action selection for the site being cleaned up.
2.
The Scope of Work should describe each task to be performed as listed in the schedule and cost estimate for
each task, see Part Ill A.
3.
The Scope of Work should indicate how funding for this grant will augment, and not interfere with, programs in
existence or technical evaluations of the same purpose.
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2530-FM-BWM0215
Rev. 12/2009
PART Ill — FINANCIAL/WORK COMPLETION DATA
Complete Part Ill — Financial/Work Completion Data form as follows:
A.
B.
C.
TASK COST COMPLETION SCHEDULE
1.
List the tasks described in Part II, Section B, Scope of Work. Enter the starting date, ending date, and cost
expected to be incurred for each task. Subdivide each cost into the portion to be reimbursed by DEP and any
share that will be financed by the municipality. Include all expenses, i.e. materials, equipment, or
expendables, as well as contractor costs. (Assets may not be purchased with grant monies.)
2.
Total Cost is equal to the total of approved task costs required to complete the Scope of Work.
BUDGET CATEGORY DATA
1.
Assign the costs described in Part Ill-A to the appropriate Budget Category in Part Ill-B. It may be necessary
to allocate portions of a single task cost to one or more Budget Items.
2.
Item 6, Other, should include any costs not covered in lines A—E, including travel costs.
3.
Agency travel must not exceed 10% of Total Approved Costs and must be limited to that occurring within
Pennsylvania and 300 miles of the agency’s official business address unless otherwise approved by the
Department.
4.
Total Approved Costs of Part B, Budget Category Data, must equal Total Approved Costs of Part A,
Task/Cost Completion Schedule.
RELATED FINANCIAL INFORMATION
1.
Travel cost mileage rates will be limited to the maximum allowable to State employees under State travel
regulations.
2.
Upon request, the municipality shall provide the Department’s Central Office with one copy each of all
subcontracts proposed to be executed with any consultants/subcontractors for the completion of any portion
of the Scope of Work in Part Il-B of the application and Section D of the agreement. The Department shall
also be contacted for subcontract approval of any consultant/subcontractor and subcontract that will entail the
expenditure of 50% or more of the grant funds provided. An explanation of the bid or procurement process
taken by the municipality must be included with the application form.
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Rev. 12/2009
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
APPLICATION NO.
DEPT. USE ONLY
APPLICATION FOR TECHNICAL EVALUATION GRANT
PART 1 - APPLICANT INFORMATION
PLEASE FOLLOW ALL INSTRUCTIONS AS PROVIDED
1. MUNICIPALITY:
NUMBER - BOX
2. OFFICIAL BUSINESS ADDRESS:
STREET
CITY - TOWN
STATE
ZIP CODE
PA
3. COUNTY:
4. CONTACT PERSON:
AREA CODE
NUMBER
5. CONTACT PERSON TELEPHONE NUMBER:
WHOLE DOLLARS
6. AMOUNT BEING REQUESTED:
8. WORK COMMENCEMENT CATEGORY:
7. POPULATION
A
B
C
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA, COUNTY OF
I,
, being duly sworn according to law depose and say that
I am the official authorized by the applicant agency to sign this application and that the information included in this
application and documents attached as a part of the application are true and correct to the best of my knowledge and
belief.
Sworn and subscribed before me this
day of
NOTARY PUBLIC
20
SIGNATURE OF COUNTY AUTHORIZED OFFICIAL
TITLE
1. Received in Central Office
3. Returned to Applic. for Add. Info.
5. APPROVED
DEPARTMENT USE ONLY
2. Reviewed for Completeness by
4. Additional Info. Received
DISAPPROVED
DATE
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.
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Rev. 12/2009
APPLICATION NO.
DEPT. USE ONLY
PART II A - EXECUTIVE SUMMARY
Program Name:
Municipality:
Federal I.D. Number:
Contact Person:
Telephone:
Program Cost:
Funds Requested:
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2530-FM-BWM0215
Rev. 12/2009
APPLICATION NO.
DEPT. USE ONLY
PART II B - SCOPE OF WORK
(Attach additional pages as necessary)
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2530-FM-BWM0215
Rev. 12/2009
APPLICATION NO.
DEPT. USE ONLY
PART III - FINANCIAL/WORK COMPLETION DATA
Using the Scope of Work Tasks described in PART II B, complete the following tables.
A.
TASK / COST COMPLETION SCHEDULE:
DEVELOPMENT / IMPLEMENTATION OF ACT 108 INDEPENDENT TECHNICAL EVALUATION
TASK
WILL
COMMENCE
WILL BE
COMPLETED
TASK COST
DEP COST
MUNICIPALITY COST
(Budget Item Cost Less
DEP Share)
TOTAL COST
B. BUDGET CATEGORY DATA
BUDGET ITEM
A.
PERSONNEL (Municipal employee,
if applicable as opposed to "C")
B.
MATERIALS AND EXPENDABLES
C.
CONTRACTOR COSTS
D.
TRAVEL AND SUBSISTENCE
E.
OTHER DIRECT COSTS
F.
OTHER
BUDGET ITEM COST
TOTAL COSTS
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DEP COST
MUNICIPALITY COST
(In-Kind Services if Any))
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Rev. 12/2009
APPLICATION NO.
DEPT. USE ONLY
PART III (Continued)
C.
RELATED FINANCIAL INFORMATION
1.
While in-kind services are not required, if choosing to contribute them, describe the nature of the in-kind
services rendered. Indicate the manner in which such costs were derived.
2.
Indicate the names of potential contractors that will be utilized in the development and implementation of the
program and the manner in which they were selected. Indicate how costs for their services were
established. Explain the municipality's procurement system. Include a sample agreement which will be
executed between the contractor and applicant.
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Rev. 12/2009
Pennsylvania Department of Environmental Protection
Bureau of Waste Management
Act 108
Reimbursement for Independent Technical Evaluation of
Remedial Response Site Cleanup Plan
FACT SHEET
1.
Statutory Authority
*
2.
3.
4.
Reimbursement is authorized under Section 510 of Act 108 of 1988, the Hazardous Sites Cleanup Act.
Basic Provisions
*
Reimbursement is for costs incurred (up to $50,000) by a host municipality for independent technical review of
DEP’s proposed site cleanup plan.
*
More than one grant may be awarded by DEP at a technically complex site if the cleanup operation includes
more than one phase or operable unit which necessitates the preparation of more than one proposed remedial
response plan.
*
Review of grant applications shall be by professional staff in the Department of Environmental Protection (DEP)
who have experience in the remediation of hazardous waste sites and demonstrated knowledge of required
technical areas.
*
Reimbursement is for the technical review of a cleanup plan and is not to be used for the collection and analysis
of groundwater, soil and air samples at a site.
*
The Department may withhold reimbursement for falsification of information included or submitted in support of
this application or for omission of information required to be submitted with this application.
Costs eligible for reimbursement are those associated with:
*
Obtaining and interpreting information related to the proposed-cleanup plan of a remedial response site
identified under Act 108.
*
Hiring a technical advisor/consultant or reimbursing a township/city engineer to review engineering studies,
sampling plans and other site documents.
*
Meeting with local government and the public to explain elements of the remedial response cleanup plan and
related technical information.
*
Traveling to meetings and hearings related to the specific site.
*
Mileage reimbursement will be set at the current state rate in accordance with Commonwealth Travel
Regulations.
*
Preparing comments to be submitted by an official of the municipality.
*
Administrative costs must not exceed 20% of the total grant, i.e., phone service, copying costs, office support,
printing.
Costs excluded from reimbursement are:
*
Expenses associated with completing the evaluation grant application package and issuing the request for
proposals.
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2530-FM-BWM0215
*
Expenses for technical advisors to attend training seminars or conferences.
*
Those used to pay for legal action or proceedings.
*
Any costs not directly associated with site activities.
*
Any costs connected with the purchase of any equipment and/or assets, i.e. computers, office equipment.
*
Development of site investigation data such as well drilling and testing (including split sampling).
*
Any costs connected with political or lobbying activity.
5.
Responsibilities of the technical advisor/consultant are:
*
6.
7.
Rev. 12/2009
Any documents (reports) produced by an advisor must contain the following disclaimer: The contents of this
document do not necessarily reflect the views/policies of the Department of Environmental Protection.
Procurement of Technical Advisor/Consultant Services
*
A municipality will be notified by DEP six months in advance of the availability of the proposed site cleanup
plan. Only at that time should procurement of a technical advisor/consultant begin.
*
A township/city engineer who meets the qualifications listed in Section 5 may serve as a consultant.
*
If a township/city has an engineering firm on a retainer basis, the firm may serve as a consultant if the
qualifications listed in Section 5 can be met.
*
If neither a township/city engineer nor an engineering firm on retainer serve as a consultant, then a consultant
must be secured by the competitive bid process. A process substantially similar to the Commonwealths
standard Request for Proposal (RFP) process must be used by the municipality in securing the services of a
consultant.
*
Any technical consultant who assists a municipality in preparing proposal for this purpose is excluded from
consideration for consultant services.
*
The contract will be awarded based on experience, qualifications and costs associated with the proposal. All
proposals received will be available for review by DEP prior to notification of the successful bidder by the
municipality.
*
Conflict of interest provisions must be met:

An official of a municipality must not participate in awarding a contract to any firm in which the official has a
financial interest.

An official of a municipality must not participate in awarding a contract to any firm if a member of the
official’s immediate family is employed by the firm involved in bidding for consultant services.

A consultant having any relationship with a potential responsible party at a site is precluded from serving as
a consultant for a municipality at the same site.

A consultant with any ties to a parent organization or a subsidiary performing remedial cleanup work for
DEP at the same site is ineligible to serve as a consultant for a municipality.
Application Procedure
*
Completed applications must be delivered or mailed to the Hazardous Sites Cleanup Program at the
appropriate Regional Office of the PA Department of Environmental Protection.
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