BRIAN SANDOVAL GOVERNOR STATE OF NEVADA RICHARD BRENNER Co-Chair (702) 455-7316 EMERGENCY RESPONSE COMMISSION 107 Jacobsen Way Carson City, NV 89711 (775) 687-6973 Fax: (775) 687-8798 JAMES WRIGHT Co-Chair (775) 684-7500 July 26, 2011 Dear Local Emergency Planning Committees (LEPCs), The State Emergency Response Commission (SERC) invites all eligible LEPCs to apply for a U.S. Department of Transportation (USDOT), FY 2012 Hazardous Materials Emergency Preparedness (HMEP) Planning and Training grant. Eligibility requirements can be found in SERC policies 8.1, 8.2 & 8.3. These policies are posted as appendices to the Program and Grant Management Handbook linked on our website, www.serc.nv.gov. The application kit has also been posted on this website. Please read all of the instructions and, using the template, complete the entire application. Since there are two application kits, please make sure you download the one for LEPCs. The grant period is expected to be October 13, 2011 up to September 30, 2012, depending on the scope of the grant. The application should include planning and training needs for this grant period. Training requests other than for conferences must first be made through the State Fire Marshal s office. Completed application must be delivered or postmarked by September 6, 2011. Failure to submit the application in a timely manner will result in denial of the application. Please note: due to changes in procedures at the federal level, all requests will need to be approved by USDOT prior to preparation of a grant award. This process may take some time. Therefore, please consider the timing of the project request when submitting applications during this grant cycle and the mid-cycle process throughout the year. And of course, the sooner you submit a request, the sooner we will be able to get approval from USDOT. Please contact me at 775-687-6973 or by e-mail kpabon@dps.state.nv.us if you need assistance or have any questions. Sincerely, Karen J. Pabón Karen J. Pabón Executive Director
Nevada State Emergency Response Commission Hazardous Materials Emergency Preparedness (HMEP) Grant Application Planning &Training Fiscal Year 2012 Grant application for Local Emergency Planning Committees (LEPC) The completed application must be delivered or postmarked by September 6, 2011 Failure to submit the application in a timely manner will result in denial of the application. State Emergency Response Commission 107 Jacobsen Way Carson City, NV 89711 (775) 687-6973 Page 2 of 15
Nevada State Emergency Response Commission (SERC) Hazardous Materials Emergency Preparedness (HMEP) FY2012 Grant Application Kit For Local Emergency Planning Committees This grant is to provide for planning and training to prevent, mitigate and respond to hazardous materials incidents. Application and award of grants from the HMEP funds are managed pursuant to SERC policy 8.2. SERC policies may be reviewed at www.serc.nv.gov. The source of funding is derived from a federal grant from the U.S. Department of Transportation. Funds must be accounted for separate from all other grants. The Catalog of Federal Domestic Assistance (CFDA) number for this grant is 20.703. Eligibility requirements can be found in SERC policies 8.1, 8.2 & 8.3. These policies are posted as appendices to the Program and Grant Management Handbook linked on our website, www.serc.nv.gov. The federal grant period is anticipated to be October 1, 2011 to September 30, 2012. However, funds may only be used for expenditures incurred during the grant period specified on the subgrant award. Any unexpended funds at the end of the grant period will be deobligated for reallocation by the SERC through the mid-cycle grant process. All grant applications will need to be approved by USDOT prior to preparation of a grant award. This process may take some time. Therefore, please consider the timing of the project request when submitting applications during this grant cycle and the mid-cycle process throughout the year. Please submit grant applications as soon as possible so we can start the federal approval process. The SERC will consider and award grants to LEPCs first. State agencies may be awarded grants from the remaining funds up to 20% of the original available amount. Grant funds are distributed on a reimbursement basis. However, the LEPC may request advance funding for expenses over $2,000 (SERC policy 8.5). The application format is as follows: I. GOALS - Identify what the LEPC would like to accomplish with this grant award during the period of October 2011 through September 2012. II. III. OBJECTIVES - Identify the specific approaches to achieve the goals. Objectives need to be specific and measurable. BUDGETS - List each item as a line item on the budget page and explain each request in the budget narrative. There is no maximum request amount from the planning category. The maximum request from the training category is $30,000. It is anticipated there will be $86,174 available in the planning category and $150,946 available in the training category. Examples of eligible and ineligible expenses are available on our website: http://serc.nv.gov/hmep%20grant%20allowable%20and%20ineligible%20expenses2.pdf Page 3 of 15
The complete application packet must be delivered to the SERC office or postmarked by September 6, 2011. Failure to submit the application in a timely manner will result in denial of the application. State Emergency Response Commission 107 Jacobsen Way Carson City, NV 89711 Please be prepared to make a presentation of your grant application to the Planning & Training Subcommittee and the Funding Committee. The date and location of the meetings will be announced. Please call SERC staff at (775) 687-6973 if you have questions or need assistance. Page 4 of 15
CHECK SHEET A COMPLETE APPLICATION MUST INCLUDE THE FOLLOWING Title Page (original signatures) Goals of this grant Objectives of this grant Line Item Budget Budget Narrative Certified Assurances (original signatures) LEPC Compliance Certification (signed by Chair) To be submitted prior to preparation of the grant award: Copy of the LEPC meeting minutes approving submittal of grant application RETURN THIS FORM WITH THE COMPLETED GRANT APPLICATION Page 5 of 15
STATE EMERGENCY RESPONSE COMMISSION HAZARDOUS MATERIALS EMERGENCY PREPAREDNESS (HMEP) GRANT APPLICATION TITLE PAGE Applicant: Address: Elko County Local Emergency Planning Committee (LEPC) 540 Court Street Elko, NV 89801 Local Emergency Planning Committee (LEPC) Chair: Name: Dale Lotspeich Title: Chairman Address: 180 River Street, Suite A City/Zip: Elko, Nevada 89801 Telephone: (775) 753.7073 Fax: (775) 738.4056 E-mail: Fiscal Officer: Dale@lotspeich@gmail.com Name: Debbie Armuth Title: Comptroller Address: 540 Court Street City/Zip: Elko, Nevada 89801 Telephone: (775) 753.7073 Fax : (775) 753.8583 E-mail : darmuth@elkocountynv.net BUDGET SUMMARY : PLANNING TRAINING TOTAL $3,500 $16,502 $20,002 **Round the totals up to the nearest dollar** LOCAL EMERGENCY PLANNING COMMITTEE APPROVAL: On behalf of the LEPC, I certify this body has reviewed the grant application and agrees to abide by the Federal and State procedures which are related to the acceptance of funds. Signature of LEPC Chair Date GOVERNING BODY APPROVAL: (i.e. County Commissioner, County Manager) The LEPC has the approval to apply for funding through this grant. Signature Date Rob Stokes, Elko County Manager Print name and title
GOALS: Tell the SERC what you want to accomplish with this grant. Provide a separate discussion of each goal and justify its need towards prevention, mitigation and/or response to hazardous materials incidents. The goals are general statements of desired result, and should identify intended outcomes the program has established to achieve with these funds during October 2011 to September 2012. Begin typing in this box. Goals: GOAL 1: Elko County Local Emergency Planning Committee (LEPC) will continue to implement its Hazardous Materials Emergency Response Plan. This goal will be accomplished by training a maximum of 20 public sector employees to the Hazardous Material Technician Level; which is the next competency level required for personnel who are working with prevention, mitigation and response to hazardous material incidents. GOAL 2: Plan for mission-specific competencies within the NFPA 472. Identify training that meets the core competency requirements which will be include exercises and drills for identified local risks. GOAL 3: Technicians must complete the required classes as outlined in NFPA 472 and successfully complete a written and practical examination for State of Nevada Occupational Safety Health Standards for General Industry OSHA 29 CFR 1910.120(q) (8), WAC 296-62 Part R OBJECTIVES: How do you plan to achieve your goals? Include specific uses of this grant. Objectives focus on the methods/activities to be used to achieve the goals they support. Answer these questions in each objective: WHAT will be done? WHO will complete the tasks? WHEN will the activity be implemented? Begin typing in this box. Objectives: Objective 1: Meet the training standards of NFPA 471,472 and 473; to prevent, mitigate and respond to any one or all of the assessed risks identified for Elko County; i.e. highway Interstate 80, and multiple State Routes; two (2) Railroads UP Railroad including hazardous material route and fixed facilities that span Elko County, as well as, neighboring counties in Northeast Nevada and surrounding states. It is anticipated that the training will encompass two (2) public sector employees, who have been trained to the operations, decon and hazardous materials level from the key communities. i.e. Elko, West Wendover, Carlin, Wells, Jackpot and addition surrounding communities. Objective 2: The LEPC grant committee will obtain two bids from qualified instructors in which 20 (twenty) public sector employees, who have been trained to the operations, decon and hazardous materials levels. This will include instruction fees, lodging, per-diem rate for food, weekly car rental/with fuel, student manuals/printed materials and shipping of equipment/manuals and facility rental (if required). a. Request that 2 instructors fly/drive to Elko, Nevada Additionally, for public sector employees attending the training, whom reside outside the 50-mile radius, will receive per-diem State Rate (GSA). http://www.gsa.gov/ for lodging and food. There is no charge Page 7 of 15
for taking the class. Objective 3: Training, exercises and drills will be completed between October 2011 and June 2012. This will be coordinated with the availability of attendees and instructors. who have been trained to the operations, decontamination and hazardous materials level and are prepared to move to the next level. BUDGETS: Training: Instructional Fees: (2 Instructors @ $90.00) per hour $ 7,200 Lodging: (GSA Rate @ $77.00 plus tax) 6 nights Instructors; 2 rooms $ 1,044 Lodging: (GSA Rate @ $77.00 plus tax) 6 nights Students; 6 rooms $ 3,132 Meals: (GSA Rate @ $46.00 per day) 2 Instructors; 7 days $ 644 Meals: (GSA Rate @ $46.00 per day) 6 Students; 6 days $ 1,656 Car Rental/with fuel: Mileage pending (Reno or Salt Lake City) $ 450 Student Manual/printed materials $ 700 Shipping equipment/manuals $ 200 Mileage/State Vehicles (West Wendover, Jackpot, Wells) 708 miles combined @.55 per mile $ 390 Training Suits (equipment/hazmat) 3 Level B suits $ 1,086 TOTAL TRAINING: $16,502 Planning: Facility Rental (if required) $ 2,500 Technical Staff/support planning effort $ 1,000 TOTAL PLANNING: $ 3,500 TOTAL BUDGET $20,002 PLANNING: Requests to contract with a consultant must be accompanied by at least two competitive bids. The bids must include an itemized quote and detailed scope of work from the consultant. CONSULTANT/CONTRACT SERVICES: Name Type of service Amount requested NorthWest Environmetrices; Ross Glass Technician Training Hazardous Materials $10,630 IAFF Hazmat Training Team Technician Training Hazardous Materials $51,176 Fire Science Academy Technician Training Hazardous Materials $18,866 TOTAL PLANNING (round up total only) $ Please see attached for itemized quotes and detailed scope of work from consultants. TRAINING: All training requests, except for conferences must first be made through the State Fire Marshal s office (SFM). If the SFM declines the training, the request may be included in the grant application along with the letter of declination. All expenses must be itemized. State per diem rates (which follow federal GSA rates) will prevail unless local Page 8 of 15
rates are less. For the current GSA rates see http://www.gsa.gov/. Hotel receipts are required for all lodging reimbursement requests, including in-state lodging. Meals included in registration fees will not be reimbursed. Travel requirements are further defined in SERC policy 8.5. Mileage will be reimbursed at the State rate, currently 55 per mile. If a personal vehicle is used for personal convenience, the reimbursement will be 27.75 per mile. Rental cars must be pre-approved by the SERC. TRAINING COSTS: Course title Registration Hazardous Materials Technician 40/80 hours; NFPA 472; OSHA 29 CFR 1910.120(q) Cost per attendee Number of attendees TOTAL $459.30 20 $ 9,186 Hotel Per diem Transportation Cost per night Number of nights Number of rooms TOTAL $ 77.00 + tax = 87.00 6 8 $ 4,176 Cost per day Number of days Number of attendees TOTAL $46 6/ 7 for instructors 20/(6 ppl + 2 instructors on per-diem) $2,300. # of miles (round trip) x.55/mile or.25/mile # of vehicles TOTAL 354 Students $195 + $450 (Instructors) 4 $840 Cost of airline ticket Number of tickets TOTAL Parking Cost per day Number of days Number of vehicles TOTAL $ $ TOTAL TRAINING (round up total only) $16,502 BUDGET NARRATIVE This is an explanation of the line items identified in each category. Justify the relationship between the items listed within each category and the project activities. Budget narratives must be included for each category for which there is a request for items/services. PLANNING CATEGORY: Item: Facility Rental Title 49 Transportation, Chapter 1; Part 110 Hazardous Materials Public Sector Training and Planning Grants; Section 110.40 (a) (5). Conduct of emergency response drills and exercises associated with emergency preparedness plans. It is the intent of the Elko County LEPC to secure a facility that is large enough to accommodate 20 public sector employees that will be attending the Hazardous Material Technician course as outlined by NFSA 472; OSHA 29 CFR 1910.120(q) (8); WAC 296-62 Part R. This facility must have enough room to conduct all the drills and exercises associated with the course. TRAINING CATEGORY: Item: Instruction Fees, Lodging, Meals, Transportation, Training Materials Title 49 Transportation, Chapter 1; Part 110 Hazardous Materials Public Sector Training and Planning Grants; Section 110.40 (b) (2),(3),(4),(5). (2) Delivery of comprehensive preparedness and response training to public sector employees. This Page 9 of 15
includes design and delivery of preparedness and response training to meet specialized needs. Additionally, financial assistance for trainees and for instructors/trainers, if appropriate, such as tuition, travel expenses to and from a training facility, and room and board while at the training facility. Elko is the county seed and is centrally located for the key communities offering the most economical travel and lodging location for the Hazardous Materials Technician Course. Lodging, meals and transportation will all fall within the State of Nevada Per-diem as per the GSA rate schedule. (3) Emergency Response drills and exercises associated with training, a course of study and tests and evaluation of emergency preparedness plans. Training public sector employees to Hazardous Materials Technician course meets the mandated requirements for hazardous materials technician in accordance with federal OSHA 29 CFR 1910.120(q) (8); NFSA 472; WAC 296-62 Part R. Additionally, by providing the training, drills and exercises will meet Goal 1, Goal 2 and Goal 3. (4) Expenses associated with training a person (including a department, agency, or instrumentality of a State or political subdivision thereof or an Indian tribe) and activities necessary to monitor such training including, but not limited to examinations, critiques and instructor evaluations. It is the intent of the Elko County LEPC to provide the necessary training to prevent, mitigate and respond to any one or all of the assessed risks identified for Elko County; i.e. highway Interstate 80, and multiple State Routes; two (2) Railroads UP Railroad including hazardous material route and fixed facilities that span Elko County, as well as, neighboring counties in Northeast Nevada and surrounding states. In doing so, we must include the key communities and surrounding towns. (5) Provision of staff to manage the training effort designed to result in increased benefits, proficiency and rapid deployment of local and regional responders. Elko County and surrounding counties/state lines are located in the Northeast corner of the State of Nevada. This is considered rural areas. Any assistance from major cities would take hours to assemble, thus potential hazardous materials could cause extensive harm and damage not only to the local residents, but to other residents, livestock, etc. in outlying communities. Thus, it is essential to have hazardous material technician responders in the key communities can provide prevention, mitigation and response to hazardous material events. Item: Training Suits (equipment/hazmat; Hazardous Materials Emergency Preparedness (HMEP) Grants Program. Training Equipment, such as training suits, is allowable up to 5% of the total grant. Training equipment must be associated with a particular course funded by HMEP. This is essential equipment for this course in order to experience real-life seniors during the drills and exercises for the Hazardous Material Technician Course. A quote for Level B; Dupont, Tychem Responders CSM; coveralls w/sealed seams, medium is included. Cost is $362.00 for each suit. Order 3 suits. PLANNING SERVICES- Explain the basis for selection of each consultant and describe how the service to be provided is essential to achieving established goals. Begin typing in this box. Page 10 of 15
Research for consulting/instruction firms were identified based on certified instruction which meets the courses mission-specific competencies with the NFPA 472 and/or Hazmat Material Technician. The instruction must meet or exceed minimum requirements set for State of Nevada Occupational Safety Health Standards for General Industry OSHA 29 CFR 1910.120(q) (8), WAC 296-62 Part R Additionally, selection was based on a firm providing two (2) instructors willing to travel to Elko, Nevada at a reasonable rate for 20 public safety employees/students. By bring the instructors to Elko versus sending 20 students to the firm made financial sense. The University of Nevada Fire Science Academy is the only institute, which offers the Hazmat Material Technician Course within Elko County. However, it was identified by the LEPC grant committee that the UNR Fire Science Academy bid/fees exceeds the costs for training compared to hosting this training and bringing two instructors to Elko. Thus, the LEPC grant committee agreed to locate two consultants from outside Elko County. TRAINING- Explain the purpose of the training and how it relates to achieving established goals. Begin typing in this box. SARA Title III and OSHA mandates that all emergency personnel who respond to a hazardous materials incident shall be trained to the level that he/she is expected to perform at the incident. (The OSHA standard (1910.120(q) sets minimum requirements for training emergency response personnel who may be required to respond to hazardous material incidents.) All personnel must receive training prior to being permitted to take part in actual emergency operations at an incident involving hazardous materials. There are four training and competency levels recognized by Elko County in addition this required training is outlined in the Elko County Hazardous Materials Emergency Response Plan, ver. 2.0. 1. First Responder Awareness 2. First Responder Operational 3. Hazardous Material Technician 4. On-Scene Incident Commander Elko County commissioners have determined that we do not have hazardous material technician response capability within the Elko County. Thus, are requiring LEPC to coordinate training and compliance with the SERC directive. CERTIFIED ASSURANCES Page 11 of 15
Upon acceptance of FY 2012 HMEP grant funding from the State of Nevada Emergency Response Commission (SERC), the lead governmental unit hereby agrees to the following Certified Assurances governing the awarding of funds. A) FINANCIAL REPORTS The recipient agency is required to submit, at a minimum, quarterly financial reports to the SERC. Reporting must be made in accordance with all applicable federal, state, and local laws and regulations, and SERC policies 8.5 and 8.6. No expenditures or obligations will be eligible for compensation if occurring prior to the award period. All funds need to be obligated by the end of the grant period and expended by the final report date as stated in the grant award cover letter. Failure to submit proper reports pursuant to current policies may jeopardize future funding from the SERC. 1) Request for advance: May be used only if expenses total over $2,000.00 and is accompanied by a dated purchase order or quote. 2) Report on expenditure of advance: Show the actual expenditure of the advanced funds. This report is due within 30 days of the date of the advanced check and must include copies of dated invoices and proof of payment. If the amount advanced is more than the amount spent, or the advanced amount is not spent within the 30 days, the unexpended funds are to be returned to the SERC within 45 days of the date of the check. 3) Request for reimbursement: Complete and submit a financial report form, at a minimum quarterly, for all expenditures funded by the grant. Include copies of dated invoices and proof of payment. Any other form of documentation for expenditures must be approved by the SERC staff. If additional funds are used toward the project, report those expenditures as a match in the appropriate line on the report form. 4) Quarterly report required: If there are no expenditures within the quarter, a report with an explanation of why is due by the end of the month following the end of the quarter. Due dates for quarterly reports are as follows: October 31 - for reporting period July 1 to September 30; January 31 - for reporting period October 1 to December 31; April 30 - for reporting period January 1 to March 31; and July 31 - for reporting period April 1 to June 30. 5) Final report: There will be no further expenditures, the grant is closed, and no further reports are necessary. This report is due within 45 days after the end of the award period, or anytime prior to the end of the award period if no further funds will be spent. Page 12 of 15
B) EXERCISE REPORT- Each LEPC/state agency must report to the SERC by January 31 st of each year on at least one real event and/or tabletop, functional, or full-scale exercise or drill which tests the hazardous materials emergency response plan. C) GRANT CHANGE REQUEST - Grant expenditures are authorized for the purposes set forth in this application, as approved in the award, and in accordance with all applicable laws, regulations, and policies and procedures of the State of Nevada and the applicable federal granting agency. Any request for change in the project must be submitted to the SERC and approved in writing prior to its implementation. Approval may be required by the federal granting agency and/or the Funding Committee if the change is significant (SERC policy 8.7). D) The applicant certifies, through the submission of the grant application for funding, neither the lead agency, county government nor any of its participating agencies are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in the transaction by any federal department or agency. E) The applicant assures the fiscal accountability of the funds received from the State Emergency Response Commission will be managed and accounted for by the lead agency s chief comptroller; and internal control and authority to ensure compliance with SERC s documentation, record keeping, accounting, and reporting guidelines will reside with that individual. F) The applicant assures documents and personnel will be available to: the awarding agency; state Department of Administration, Division of Internal Audits; Legislative Counsel Bureau; and any other entity as required by law to audit the recipient. G) The applicant assures it will maintain all documents needed for an audit and respond to auditor inquiries in a timely manner. H) The applicant will abide by audit requirements as specified in OMB Circular A-133, Audits of State and Local Governments as revised 2003. I) The applicant and its contractors will comply with the nondiscrimination requirements of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973; Title IX of the Education Amendments of 1972; the Age Discrimination Act of 1975; and the American Disabilities Act of 1992. J) Any publication (written, visual, or audio) issued by the recipient describing programs funded whole or in part with federal funds, shall contain the following statement: This program was supported by Grant #, awarded by the Nevada State Emergency Response Commission (and, if a HMEP grant, the U.S. Department of Transportation). Points of view or opinions contained within this document are those of the author and do not necessarily represent the official position of policies of the State Emergency Response Commission (and, if a HMEP grant, U.S. Department of Transportation). Page 13 of 15
K) The applicant fully understands the State Emergency Response Commission has the right to suspend, terminate, or de-obligate grant funds to any recipient that fails to conform to the requirements or the terms and conditions of its grant award. L) LOBBYING - No grant funds appropriated will be paid, by or on behalf of the recipient, to any person for influencing or attempting to influence an officer, employee, or a member of Congress, or an officer, employee, or any member of the Nevada State Legislature. M) Project related income, (i.e., registration fees, royalties, sales of real and personal property) must be used for the purpose of furthering the goals and objectives of the project or program from which the income was generated. Interest earned must be returned to the State Emergency Response Commission. ****************************************************************************** ORIGINAL SIGNATURES REQUIRED GOVERNMENTAL UNIT (I.E. COUNTY COMMISSION, COUNTY MANAGER) Signature Date Rob Stokes, Elko County Manager Print name and title LOCAL EMERGENCY PLANNING COMMITTEE CHAIRMAN Signature Date Dale Lotspeitch, Chairman Print name and title RETURN THIS FORM WITH THE COMPLETED GRANT APPLICATION
LEPC COMPLIANCE CERTIFICATION The following requirements must be met by the LEPCs for compliance with federal, State and SERC laws, regulations and policies and procedures. This checklist must be completed, signed and returned annually by March 31, even if the LEPC is not a recipient of grant funds. A check mark in the squares on the left will indicate a YES response. Have changes in the LEPC Bylaws and Membership list been submitted to SERC? Bylaws reviewed/updated Date: _1/12/11 Submitted: 1/26/11 Membership list reviewed/updated Date: 1/12/11 Submitted: 1/26/11 Have LEPC meetings been held, at a minimum quarterly, and have agendas and minutes of all meetings, including special meetings, been forwarded to the SERC? Has the LEPC submitted all required reports which summarize the financial management of the active grants (i.e., copies of invoices and verification of expenditures)? Has the LEPC reviewed and updated its hazardous materials emergency plan (or hazmat portion of the jurisdiction s all hazards plan), NRT-1, Level of Response Questionnaire and Letter of Promulgation within the last year? Have the review results and updates been submitted to the SERC in writing along with a copy of the LEPC meeting minutes documenting review of the Plan by January 31 st? Plan update Date: 1/12/11 Submitted: 1/26/11 NRT-1 update Date: 2/3/11 Submitted: Level of Response Questionnaire update Date: Submitted: Letter of Promulgation update Date: Submitted: Has the LEPC reported on at least one incident or exercise (exercise required at least every third year) of its hazardous materials emergency response plan by January 31 st? Indicate the date of the most recent exercise: 09/10/10 Submitted: _12/8/10 Indicate the date of an incident report used in lieu of an exercise: Submitted: Has the LEPC met the annual requirement of publishing the Emergency Planning and Community Rightto-Know Act information availability in the local newspaper? Has the standard Affidavit of Publication been sent to the SERC? Date of publication: 1/31/11 Affidavit Submitted: 1/26/11 As chairman of the Elko County Local Emergency Planning County Name Committee, I attest all information provided on this compliance certification is accurate. LEPC Chair Signature Date: RETURN THIS FORM WITH THE COMPLETED GRANT APPLICATION