ABCWXYZ
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 SB20-218 PFAS Grant Program-Emergency Assistance
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PFAS sampling coordinator
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Organization:
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PFAS Sampling Coordinator Name:
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Email address:
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Telephone number:
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Mailing address:
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Fax number:
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Organization information
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PWS ID (If applicable):
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Water source:
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Organization Contact Name:
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Organization email address:
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Organization telephone number:
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Organization mailing address:
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Grant Application Date:
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Estimated population Served:
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Background information
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Grant Fund Request:
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What individual concentrations of PFOA and PFOS (the chemicals in EPA’s health advisory) were detected in samples? 
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What type of samples was PFAS detected in? (ex: treated drinking water, ground water, stream segment, etc.)
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How may people be exposed to the PFAS detected (ex: ingestion, dermal contact)?
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What is the approximate distance to the closest potential PFAS contaminant source?
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What is the closest drinking water source?
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Project Description
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Project Descripition:
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Core objective of your project/proposal (ex: treatment, sampling, emergency water supply, etc.):
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Estimated population potentially exposed:
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Will this project aid disproportionately impacted communities or schools?
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Project Classification
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Will this project be sampling or treat treated water served directly to customers and/or water sources used by public drinking water systems?
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Will this project sample or treat at-risk private groundwater wells and surface waters used for drinking or irrigation located in or near known areas of PFAS contamination that may be above health advisory levels?
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Will this project sample or treat private groundwater wells and surface waters located near potential sources of PFAS contamination that are used for drinking or irrigation purposes?
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Will this project sample or treat PFAS discharges from publicly owned treatment works or other industries with potential to impact ground and surface water?
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