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P32 <br />EXHIBIT A <br />Rice Creek Watershed District 2012 <br />RCWD Urban Stormwater Remediation Cost -Share Program <br />Application Form Supplemental <br />Incomplete applications will be returned to the applicant. <br />1. APPLICANT INFORMATION <br />Organization (to be named as Grantee): <br />Street Address: 1880 Main Street <br />City, State, Zip: Centerville, MN 55038 <br />Email: dlarson(cz,centervillemn.com <br />SLX Centerville, Circle Pines, Columbus <br />CITIES Lexington & Lino Lakes & Hugo <br />11. PROJECT CONTACTS <br />Project Officer: Dallas Larson <br />Telephone: 651 -429 -3232 <br />Fax: 651 - 429 -8629 <br />Email: dlarson@centervillemn.com <br />Tax Status: Local Unit of Government <br />Website: <br />Financial Officer: Mike Jeziorski <br />Telephone: 651429 -3232 <br />Fax: <br />Email: mjeziorski �?a,centervillemn.com <br />Tax ID #: 41- 1267014 <br />(e.g., local government, non-profit 5O1(c)(3), private business, etc.) <br />IOC. PROJECT INFORMATION <br />Project Name: Sodium Chloride Management Project <br />Location(s) of Project: Centerville, Circle Pines, Columbus, Lexington & Lino Lakes & Hugo <br />City: State: MN County: Anoka County <br />Project Completion Date: December 15, 2013 <br />Project Start Date: June 1, 2012 <br />Project Type (check only those that directly apply): <br />Q Redevelopment Project <br />El Roadway / Street Project <br />1V. COST-SHARE REQUEST Supplemental <br />Cost -Share Funds Requested: $ <br />Local Matching Contributions: $ 90,000 (cash) <br />$ (in -kind) <br />Total Estimated Project Cost: $ 1551000 <br />Would you be willing to accept cost -share funding in an amount less than requested? OYES E NO <br />Contact us to discuss reduced grant. <br />V. SIGNATURE 01 APPLICANT (An original signature page must be received with this application) <br />0 Storm Sewer / Stormwater Treatment Project <br />Other Chloride Reduction <br />65,000 <br />i certify that the information contained within this application is true and accurate. <br />Signature of Executive Director or Project Officer Date <br />Dallas Larson, Admin. Project Officer <br />Name, Title <br />Page 1 of 4 <br />• <br />• <br />• <br />