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APPLICATION FOR IiIGHWAY SAFETY PROJECT REIMBURSEMENT GRANT <br /> STATE OF HAWAII SAFE COMMUNITY PROGRAM -SAFE COMMUNITIES OFFICE <br /> PART I FOR SCP-SCO USE ONLY <br /> (Applicant to Complete) <br /> Project Number. EMOS-04 (O1-H-O1) <br /> 1. APPLICANT (Name and Address) Title: HCFD Equipment Purchase <br /> Darryl I. Oliveira, Fire Chief <br /> 25 Aupuni Street, Room 103, Hilo, HI 96720 <br /> Ssandard Area EM <br /> 2. AGENCY UNIT (Name and Address) <br /> County of Hawaii Fire Department Effective Date: 10 / 1 /04 <br /> 25 Aupuni Street, Room 103, Hilo, HI 96720 Federal Funds Obligated $ 10 ,163.20 <br /> 3. DURATION (Month, Day, Year) <br /> A. Grant Period B. Project Period FY Funds 5 Addendum _ YES X NO <br /> From: October 1, 2004 From: October I, 2004 Benefit of STATE R COUNTY <br /> To: Se tember 30, 2005 To: Se [ember 30, 200 rj <br /> 4. LOCATION OF PROJECT Sa. TYPE OF APPLICATION [Check Appropriate Item(s)] <br /> Island of Hawaii g Initial _ Revision _ Continuation <br /> County of Hawaii Fire Department <br /> At l4 ambulance units Sb. REIMBURSEMENT SCHEDULE DESIRED <br /> Monthly R Quarterly <br /> 6. PROJECT DESCRIPTION Schedule A <br /> 7. PROJECT OBJECTIVES AND TASKS SUMMARY FROM SCHEDULE A <br /> To eliminate the need to transfer patients from spinal immobilization to obtain x-rays. <br /> 8. BUDGET Schedule B <br /> 8A. COST CATEGORY Total <br /> Grant Period Expenditures Project Period <br /> Prior Years <br /> 1 PetsonalServices $163.20 n/a $163.20 <br /> 2 Consultant Services n/a <br /> 3 Commodities n/a <br /> 4 OtherDirecUlndirectCosts $10,000.00 n/a $10000.00 <br /> TOTAL ESTIMATED COSTS Inc. Non-Fed. Shaze $10,163.20 $10,163.20 <br /> 8B. SOURCE OF FUNDS $10,163.20 C. SPECIFY HOW NON-FEDERAL <br /> (I) Federal (<DD %of TOTAL) SHARE WILL BE PROVIDED <br /> 2 A licant A e 43 <br /> 9. MILESTONES Schedule C <br /> 10. AGREEMENT OF UNDERSTANDING AND COMPLIANCE See Schedule D attached <br /> 11. ACCEPTANCE OF CONDITIONS. @ is understood and agreed by the undersigned that a reimbursement grant received as a result of this <br /> application is subject to Public Law 89-564 (Highway Safety Act of 1966) and all administrative regulations governing grants established by the <br /> U.S. Department of Transportation and the State of Hawaii. It is expressly agreed that this project constitutes an official part of [he Hawaii <br /> Highway Safety Program and [hat said applicant agency will meet [he requirements as se[ forth herein, including accompanying schedules A,B,C <br /> & D, which are inco orated herein and made a art of this a lication. Authorization t rceeed with this Hi hwa Safe Project is re uested. <br /> 11A. PROJECT OR I IB. AUTH Z FICIAL OF AGENCY UNTO <br /> Si nature Si nature <br /> Name Neil Yoshioka Name a J. Oliveira <br /> Title Firefi hter/M[CT Title Fire Chief <br /> Date SEP 2 1 004 Date <br /> <br /> To be prepared by applicant, use separate sheets as required. Form HS 3-71 Rev. IO/Ol <br /> <br />