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APPLICATION FOR Version 7/03 <br /> FEDERAL ASSISTANCE 2. DATE SUBMITTED — Applicant Identifier <br /> 1. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE State Application Identifier <br /> Application Pre - application <br /> n Construction Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier <br /> 0 Non - Construction _ 1_1 Non-Construction <br /> 5. APPLICANT INFORMATION __ <br /> Legal Name: — Organizational Unit: _— <br /> Department of Water Supply County of Hawaii, Department of Water Supply ____ _ <br /> Organizational DUNS: Division: <br /> 06 -254 -3587 _ __ <br /> Address: _..— _ Name and telephone number of person to be contacted on matters <br /> Street: involving this application (give area code) _ __ <br /> 345 Kekuanaoa Street Prefix: First Name: <br /> Mr. Ryan <br /> _____ <br /> City: - - -- - -- - Middle Name -• - -- <br /> Hilo <br /> - <br /> County: Last Name ~` <br /> Hawaii Quitoriano <br /> State: Zip Code Suffix: <br /> Hawaii __ 96740 _ <br /> Country: Email: <br /> United States of America rquitoriano ©hawaiidws.org <br /> 6. EMPLOYER IDENTIFICATION NUMBER (E!N): Phone Number (give area code) Fax Number (give area code) <br /> 9 9_ 6 0 0 0 7 2 5 (808) 961 -8070 Ext. 256 (808) 961 -8080 <br /> 8. TYPE OF APPLICATION: - 7. TYPE OF APPLICANT: (See back of form for Application Types) <br /> il/ New T" i Continuation 1 -. Revision B <br /> If Revision, enter appropriate letter(s) in box(es) <br /> (See back of form for description of letters.) — _ Other (specify) <br /> _ Other (specify) 9. NAME OF FEDERAL AGENCY: <br /> U.S. Department of Agriculture, Rural Utility Service <br /> 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: <br /> .--f- --0-_..7- 6 0 Kona Ocean View Properties Water System Improvements <br /> TITLE (Name of Program): <br /> Water and Waste Disposal System for Rural Communities <br /> 12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.): <br /> County of Hawaii <br /> 13. PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF: <br /> Start Date: Ending Date: a. Applicant b. Project <br /> 6/1/10 6/1/11 Hawaii District 2 Hawaii District 2 <br /> 15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE <br /> ORDER 12372 PROCESS? <br /> a. Federal °U THIS PREAPPLICATION /APPLICATION WAS MADE <br /> 1,519,368 a. Yes. AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 <br /> b. Applicant i, 00 PROCESS FOR REVIEW ON <br /> 50,000 <br /> c. State - . °U DATE: <br /> d. Local $ 00 b. No. I J PROGRAM IS NOT COVERED BY E. O. 12372 - <br /> e. Other $ 1i OR PROGRAM HAS NOT BEEN SELECTED BY STATE <br /> ___ FOR REVIEW <br /> f. Program Income . 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? <br /> g. TOTAL $ 1,569,368 1 Yes If "Yes" attach an explanation. i No <br /> 18. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION / PREAPPLICATION ARE TRUE AND CORRECT. THE <br /> DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE <br /> ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. <br /> a. Authorized Representative__ <br /> pj efix First Name Middle Name <br /> r Milton D. <br /> Last Name Suffix <br /> Pavan _ <br /> b. Title - c. Telephone Number (give area code) <br /> Manager (808) 961 -8050 <br /> d. Signature of Authorized Representative e. Date Signed /2/749 <br /> Previous Edition Usable Standard Form 424 (Rev.9 -2003) <br /> Authorized for Local Reoroduction Prescribed by OMB Circular A -102 <br />