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Instructions for Completing "Request for Technical Assistance (TA)" SECTION A Community, System, or School Name: Enter the full name of the organization or community needing TA. Public Water System ID: If the organization is a drinking water system, provide the Public Water System ID. Otherwise, enter "N/A". County: Enter the county of the organization needing TA. Number of Service Connections: Enter the number of active service connections in the service area needing TA. Service Area Population: Provide the population of the service area needing TA. Type of Organization: Check the box that best describes the type of organization in need of the TA. Estimated Median Household Income (MHI): Enter the estimated MHI for households within the service area, if known. The only MHI sources accepted by the State Water Board are (1) 5-years American Community Survey (ACS) data and (2) income surveys previously validated by the State Water Board. If the organization needing TA is a school, enter "N/A." Estimated percentage of second or vacant homes: Estimate the percentage of homes within the service area which are occupied for less than six (6) months of a year. Service Area Map: Provide a copy of the service area map for system. SECTION B Type of TA Need: Check the box indicating the type of TA need being requested. Requests for more than one type of TA need should be submitted on separated forms. SECTION C Problem: Describe the problems/needs of the system, such as water quality issue, water supply shortage, capital improvement needs, etc. SECTION D Request: Describe the TA being requested. Examples of TA provided include: • Funding application • Community outreach • Engineering services • Income survey • Rate study • Environmental services • Leak detection • Legal assistance • Hydrogeological analysis Is the regulatory agency supportive of this project? Indicate if the request has been discussed with someone from a regulatory agency, such as the Regional Water Board, the Division of Drinking Water, or the Local Primacy Agency. If yes, provide the names of the primary contact person and the agency. Is this request associated with a compliance order? Indicate if TA is being requested to address a compliance order. If yes, enter the compliance order number. Attach a copy of the compliance order when submitting the request. SECTION E Contact Information: Provide a contact for follow up correspondence from the State Water Board. SUBMISSION: Please email completed forms to: DFA-TAReguest(a)_waterboards.ca.go, . On the e-mail subject line, include the name of the organization that will be the TA recipient. You are encouraged to submit any supporting documentation demonstrating the TA needs. Examples include copies of compliance order, sanitary survey, water system's maintenance logs, etc. All supporting documentation may be submitted as attachments when e-mailing the request form.