2010-11-24 CC Packet - Laserfiche WebLink

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• MINNESOTA ' � Environmental Health Aivision Drinking Water Protection Section P.O. Box 64975 pEfARi or EAl St. Paul, Minnesota 55164-0975 Community Fluoridation Grant Application Notice: This application must be completed in order to score your grant request. Public Water Supply System (name of primary applicant): City of Centerville ....................................................................PWSID: 10200036.......... Note: List all of the public water supply systems involved if more than one is applying: ............................................................................................................................ Name of the Grant Contact: Mike Jeziorski ............................................................... Phone No. 651-429-3232...... Ext: ......... E-mail address: mjeziorski@centervillemn.com........ Mailing Address 1880 Main Street Centerville, MN 55038 ................................................... � Federal Tax ID #: 41-1267014 ........................................................................ i Person Authorized to Sign Grant Agreement on Behalf of the Public Water Supply System: I Name: Mary Capra Title: Mayor � • Total Grant Amount Being Requested ($7,500 maximum): $ 2,978.08 I Work Item (s) to be performed under this grant I For each work item to be funded under the grant, please provide the following information (use an additional page if necessary). I I 1. Work Item — describe the work that will be performed: Upgrade fluoride feed equipment per MN Department of Health recommendation la. Amount Requested for perfornung this work: $ 2,978.08 lb. Fluoridation Process Equipment type: _ New _x_ Replacement lc. Product(s) produced or anticipated outcomes of perfornung this work item: The anticipated outcome is to have a fully compliant system. • 47