DRINKING WATER STATE REVOLVING FUND

LETTER OF INTENT

Regulation for Letter of Intent may be found in NAC Chapter 445A, NAC 445A.6751 to 445A.67644. This Letter of Intent to proceed with the proposed water project as listed on the current approved Project Priority List will serve as a request to the Division of Environmental Protection to initiate the process of environmental review pursuant to NAC 445A.6758 to 445A.67612, inclusive.

Project name:
Water system name if different: / System I.D. #
Name of contact person: / Title:
Company name if different
than water system name:
Address:
Telephone: / Fax:
Location of project:
Description of project (please attach maps and preliminary plans):
No. of residential service connections: / Population served:
No. of non-residential service connections: / Population served:
Preliminary estimate of the cost of the project: Planning ______Engineering ______Construction ______Include any other costs necessary for financing the project. Please attach any documentation (such as a preliminary engineering report) necessary to support the development of costs.
Description of planned future improvements that are not part of this project:
How will this project enable the system to comply with State and EPA requirements for public water systems?
Has a plan for water conservation been filed with the appropriate agency?
Yes ____ Name of agency: ______
No ____ If no, when will it be filed? ______
Anticipated schedule for filing loan application and proceeding to construction (by calendar year quarter):
Environmental Review Information (Please attach Form Request for Environmental Information.)
I request categorical exclusion.
I do not request a determination as to whether or not our project is eligible for a categorical exclusion.
What is the anticipated source of revenue to repay the loan? (Please include a description of any necessary authorizations for such repayments.)
Describe the amount, type and source of any other funding for this project.
Additional comments or information (attach additional pages if necessary):
Signature of applicant: Date:
Printed name and title:

*This Letter of Intent and the Environmental Information Request Form should be addressedand sent to:

Division of Environmental Protection

Office of Financial Assistance

901 S. Stewart St., Suite 4001

Carson City, NV 89701-5249

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