6100-078 Water TA Request Form & Needs Assessment

^{OMB Control Number: 2030-0051}

_{Expiration Date: XX/XX/XXXX}

Water Infrastructure

Water Technical Assistance Request Form & Needs Assessment

Complete the following form to request Water Technical Assistance (WaterTA) services. 

The EPA's WaterTA aims to assist communities with applications for federal funding, quality water infrastructure, and reliable water services in partnership with drinking water, wastewater, and stormwater utilities and local government. WaterTA cannot provide direct assistance to federal facilities. Before submitting a request, we encourage you to learn more about who can receive WaterTA services and the challenges WaterTA can help your community address. Contact [email protected] if you have any questions regarding your organization's eligibility. 

If you include your email address in your submitted form, you will receive a confirmation email from [email protected]. After reviewing your submission, the EPA or a technical assistance provider will respond with potential next steps. Response times may vary depending on the volume and types of requests we receive. Many states also offer WaterTA programs. Thus, the EPA may share your request with the appropriate state agency in an effort to provide the best, most timely assistance.

Please note not every request may be offered WaterTA, and participation in this or other EPA technical assistance programs does not guarantee funding through the State Revolving Funds (SRFs) or other programs.

For more information on WaterTA, visit www.epa.gov/WaterTA. To receive updates on EPA programs, helpful resources, and notifications of upcoming webinars and training events, sign up for the EPA's Water Infrastructure and Resiliency Finance Center email list. If you have any questions or concerns about the WaterTA Request Form, please contact [email protected].

Burden Statement: 

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0051). Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 3 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Director, Information Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

First name

Last name

If you would like a response, please include your email address and/or phone number.

Email

Phone number (xxx-xxx-xxxx)

How are you affiliated with the community or water system of interest?

• City/town administrator or staff

• Community-based organization

• Community member/customer/resident

• Elected official

• Engineer for utility (staff/consultant)

• Tribal utility administrator or staff

• Tribal elected official

• Utility administrator/staff

• Utility board/committee member

• Other: _______________

City/Town *

City where the community or water system of interest is located.

County *

County where the community or water system of interest is located. You may type "N/A" if not applicable.

State/Territory *

- Select -

Tribe/Pueblo

PWSID or NPDES permit number (if applicable/known)

Please format your permit number to include the state abbreviation (e.g., “TX0000000”).

Name of Drinking Water or Wastewater System (if applicable/known)

Population size served *

- Select -

500 or fewer

501-3,300

3,301-10,000

10,001-100,000

100,001 or greater

Unsure

Type of system or project (select the best fit) *

This information will be used to direct your request to the best fit program. If you have additional needs, you can describe them in the text box below.

• Drinking water

• Wastewater

• Stormwater

• Source water protection

• Nonpoint source

• Decentralized wastewater (e.g., septic systems)

• Multiple types of systems or projects

• Other

If you know the assistance you would like to be considered for, please select below (select the best fit). This information will help expedite processing of the request. A blank response will be considered for all WaterTA options.

• General Water Technical Assistance

• Participation in Closing America’s Wastewater Access Gap (failing septic system/rural wastewater improvements)

• Participation in Get the Lead Out Initiative (lead service line replacement planning)

• Engineering Planning Support (e.g. Needs Assessment, Preliminary Engineering Report) for State Revolving Fund Application Materials

Briefly describe your water quality or infrastructure concerns as they relate to this request for technical assistance. Please be as specific as possible. *

(750-character maximum limit; NO bullets or numbered lists)

- Select -

Yes

No

Unsure

Is your community currently working with a TA provider? *

If yes, please provide TA Organization’s Name.

Does your community qualify as a “disadvantaged community” within your state or meet your state's affordability criteria? As defined by your state's Drinking Water or Clean Water State Revolving Fund program.

- Select -

Yes

No

Not applicable (as may be the case for Tribes and Territories)

Unsure

EPA Form Number: 6100-078