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319-U, URBAN COST-SHARE CLEAN WATER ACT SECTION 319 COST-SHARE PROGRAM
State Form 50063 (R2 / 3-09) INSTRUCTIONS: See page 2 of this form.

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGAMENT

SECTION A
Applicant name Name of sponsoring Organization Indiana county IDEM Contract/Agreement number

Location information (where applicable) Street address Township

City Range Civil township

ZIP code USGS quad name

Section number 12-Digit HUC

Latitude & longitude or universal transverse mercatur (UTM) coordinates

I hereby agree that all best management practices (BMPs) implemented with these grant funds will be operated and maintained in accordance with United States Department of Agriculture Natural Resources Conservation Service (NRCS) standards and specifications or other specifications cited below. Practices shall be maintained as follows: structural practices on residential land, vegetative practices, and land management practices five (5) years; structural practices on non-residential land ten (10) years. Low Impact Development and Conservation Easements do not require maintenance.
Applicant signature Printed name Address (full street address) City State, ZIP code Date (mm/dd/yyyy) Landowner Signature Printed name Address (full street address) City State, ZIP code Date (mm/dd/yyyy)

SECTION B
The following eligible BMPs are needed to improve or maintain water quality, and will reduce excess flow, and/or sediment, nutrient, pesticide, and pathogen loads to receiving waters. These practices were implemented consistent with NRCS standards and specifications or other specifications listed below and do not satisfy MS4 or NPDES permit requirements. Install Date CostBMP Name or NRCS Title Standard and Maintain Ft2 or Total Costshare Specification units of Cost share (mm/dd/yyyy) for BMP Level (%) Amount yrs $ $ yrs yrs yrs $ $ $ $ $ $ $ $ Date (mm/dd/yyyy)

TOTAL

Printed name and signature of NRCS, ISDA, TSP, PE, lawyer, contractor, or SWCD technical representative taking responsibility for the correct installation of the BMP(s): SECTION C Critical area as described in the WMP and page number(s) where referenced

NPS pollutant(s) of concern addressed within this critical area by BMP implementation

The total cost-share amount in section B is recommended to IDEM for cost-share assistance and is approved for payment by the sponsoring organization. Authorized signature of sponsoring organization Date (mm/dd/yyyy)

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INSTRUCTIONS FOR COMPLETING STATE FORM 50063, 319-U
This form should be completed when requesting reimbursement from the Section 319 Program for eligible cost-share and/or demonstration best management practices (BMPs) implemented on urban land; defined as forests, wetlands, mining areas, and land that is currently not cropland, pastureland, rangeland, native pastureland, other land used to support livestock production, or tree farms. SECTION A ­ This section requests general information on the BMP location and applicant/landowner. Complete all applicable blanks in Section A for the BMPs implemented and listed in Section B. · If the applicant does not own the land where the BMP will be implemented, the landowner's signature is required, unless the applicant has power of attorney for the landowner. The landowner must sign the form before proceeding with the project. · Include the twelve (12) digit Hydrologic Unit Code (HUC), and the latitude & longitude or the UTM coordinates for a central location where the BMP is implemented. If many BMPs are implemented in different places, one (1) general coordinate location will suffice. · Before signing, the landowner must understand the certification statements above the signature block. SECTION B ­ This section certifies that the BMPs are needed to improve or maintain water quality and were satisfactorily completed. · Complete the BMP name or U.S. Department of Agriculture Natural Resources Conservation Service (NRCS) Practice title, specification followed, maintenance required (based on Section A), square footage or number of units of the BMP (whichever is applicable), total practice cost (shown on attached receipts), percent of the total cost to be paid to the landowner, total amount paid to the landowner, and date the BMP was implemented. IDEM will accept specifications from sources other than NRCS and other government agencies. Specifications do not have to be submitted, but must be producible if IDEM requests to view them. Urban Demonstration Practices may have a cost-share level of up to 100%. See definition of Demonstration Practice below. · This section must be completed and signed by a NRCS representative, Indiana Department of Natural Resources (IDNR) representative, Professional Engineer (PE), lawyer, contractor, or Soil and Water Conservation District (SWCD) Technical Representative who can certify to the statements at the top of Section B. In lieu of standards and specifications for Low Impact Development (LID) and conservation easements, include the name of the company who completed the design or created the easement. A PE's signature is needed to certify that LID was properly done and a lawyer's signature is needed to certify that a conservation easement was placed on the applicant's land. SECTION C ­ This section must be complete and signed by an official (with signatory authority) of the sponsoring organization. · From the approved watershed management plan (WMP) (or draft WMP if implementing a demonstration BMP), reference the critical area where the BMP(s) were implemented and what nonpoint source (NPS) pollutants of concern within that critical area are being addressed. FORM SUBMISSION ­ An invoice for payment should be prepared and submitted to IDEM with this form. As individual practices are implemented, invoices may be submitted to IDEM. Payment will be directly deposited in the sponsoring organization's account in approximately four weeks. The following items must accompany this complete, signed 319-U Form and an invoice for payment to IDEM: 1) Map, showing location of all BMPs/practices in relation to adjacent roads; 2) Copies of bills or receipts for each BMP showing the total cost; 3) Copies of the Region V Load Estimation Model worksheet(s), the STEPL model workbook, the Simple Method calculations or other appropriate loading tool for the BMPs implemented. The Region V and STEPL models can be found on EPA's web site at: http://it.tetratech-ffx.com/stepl/models$docs.htm. The Simple Method can be found in IDEM's Clean Water Act Section 319 Urban Guidance for Indiana. Load calculations are not needed for LID or conservation easements. Rain barrels do not require load reductions unless 250 or more were installed in the watershed as a result of the project. ADDITIONAL INFORMATION ­ For more information on the cost-share program and requirements, see IDEM's Clean Water Act Section 319 Urban Guidance for Indiana or contact your IDEM project manager. Note to sponsors: The sponsoring organization may need to provide a 1099 Form for disbursements. DEFINITIONS: Demonstration Practice ­ a BMP used to introduce new NPS reduction techniques in the watershed and to encourage landowners to install the practice. The BMP must: be located on public land and in a critical area as defined in the WMP, not have been cost-shared on before in the watershed with Section 319 funds, and be used/showcased as part of an education/outreach event. Demonstration practices must be authorized in the project's grant agreement and implemented according to the instructions on this form. Land management practice ­ Practice that requires primarily management techniques and methods to implement the practice. Examples of urban land management practices include LID and conservation easements. Residential Land ­ Any piece of residential property with one unit of housing. For the purposes of Section 319 funding, apartment complexes and common spaces within housing developments are not considered residential. Individual houses leased as apartments are considered residential. Landowners must maintain the practice as long as they own the property, or five (5) years, whichever is less. Structural Practice ­ Practice that involves constructing designed (engineered) features using machinery. Examples of urban structural practices include 2-stage ditches, streambank stabilization, porous pavement, rain gardens, rain barrels, and green roofs. Vegetative Practice - Practice that only involves seeding or planting to establish or re-establish plant cover. Examples of urban vegetative practices include filter strips, tree plantings and other simple plantings.

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