1. 3850-FM-BCW0284 Rev. 1/2018 COMMONWEALTH OF PENNSYLVANIA
  2. INSTRUCTIONS FOR
  3. FILING COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES FOR
  4. AND SMP ANNUAL REPORT
    1. FOR APPLICATION YEAR ENDING December 31, 20

 

 

 

 

 

 

 

Combined

Application for Reimbursement of Expenses for

Sewage Management Program (SMP) Administration

Under the Pennsylvania Sewage Facilities Act

and

SMP Annual Report

 

 

 

 

 

 

 

 

 

               
For more information, visit www.dep.pa.gov
3850-FM-BCW0284 Rev. 1/2018
   
3850-FM-BCW0284 Rev. 1/2018 COMMONWEALTH OF PENNSYLVANIA
Instructions DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER

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INSTRUCTIONS FOR

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FILING COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES FOR
SEWAGE MANAGEMENT PROGRAM (SMP) ADMINISTRATION
UNDER THE PENNSYLVANIA SEWAGE FACILITIES ACT

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AND SMP ANNUAL REPORT

New SMPs, in order to gain the Department of Environmental Protection (DEP) reimbursement recognition, must be established by the process of an update revision to the municipal or regional Official Sewage Facilities Plan (Official Plan), including adoption of the plan by resolution of the affected municipality and approval by DEP.

Please read all instructions carefully before completing your application. If any of the information or supporting documentation is not submitted, unsupported costs will be deducted from total expenses prior to calculating your reimbursement.  Questions may be referred to 717.787.5017.

Municipalities that are not the local agency (LA), but which administer their own SMPs, should use this form only to file for reimbursement of their SMP expenses. These municipalities should not submit a Combined Application for Reimbursement for Enforcing the Pennsylvania Sewage Facilities Act and Onlot Sewage Disposal Program Annual Report form (3850-FM-BCW0280). Both forms are available electronically in DEP's eLibrary online at www.dep.pa.gov .

Applications concerning SMP expenses cannot be submitted directly by or on behalf of municipal authorities. Only LAs, or municipalities that meet the requirements of 25 Pa. Code §71.73(d) are eligible to apply for reimbursement of SMP expenses.

"First time" SMP reimbursement applications must include a copy of all municipal ordinances, acts, regulations or procedures used in administrating the applicant's SMP. Subsequent submissions must include a copy of any additions, deletions and amendments made during the preceding calendar year to municipal ordinances, acts or procedures that affect the program.   

DEADLINE:  Applications must be received by DEP no later than March 1, 2018.

     
Submit your application to:  Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P. O. Box 8774
Harrisburg, PA 17105-8774
COMPLETE ALL SECTIONS AS INDICATED:
SECTION A.
a. Item 2 - The municipal official must be an elected official or a person appointed to a responsible position with the municipality, such as the Municipal Secretary or the Chairman of the Board of Supervisors.  A Sewage Enforcement Officer (SEO) cannot be named as the official.
b. Item 8 - If your county has a county health department, enter its name here. If your municipality is served by a multimunicipal agency for permitting of onlot sewage disposal systems only, enter that agency name here.
SECTION B. Complete after Sections C and D are completed.
SECTION C.
a. List only SMP reimbursable expenses.  Eligible costs include administrative, personnel and equipment costs associated with SMPs.  These expenses must be itemized and completely documented by one copy of the Activity Record, Section F, or invoices equivalent to the form. Activity records or invoices must identify the specific person who performed each activity. Expenses under each cost category must be totaled in the right-hand column under "Total Expenses," and this total must be entered in Section B.1.
25 Pa. Code §72.44 contains a complete listing of eligible and ineligible costs for reimbursement of sewage facilities permitting programs.  Where applicable, these listings also apply to SMP reimbursements.  Justification must be submitted to support reimbursement requests for unlisted categories. Questions on eligibility of specific items can be asked by calling 717.787.5017.
b. One copy of proof of payment (canceled checks or other records acceptable to DEP) must be submitted for all expenses claimed.
Expenses which are not supported by the above documentation will not be considered for reimbursement. Your claim for expenses must be consistent with 25 Pa. Code §72.44 available electronically at www.pacode.com .
SECTION D. Enter the revenue from SMP related fees, fines, other money and uncollected revenue (money owed to the municipality). Enter the total revenue here and in Section B.2.
SECTION E. Enter the individual fees and fines assessed to system owners under the SMP. Do not enter total fees, fines or other income received.
SECTION F. Activity Record. Submit copies of DEP activity records or invoices equivalent to the form.
SECTION G. Completion of this section is required. This section is being used to track program activity statistics.
SECTION H. This affidavit should be executed by the municipal official designated in Section A, who is sworn by a notary public. The seal and signature of the notary public must be affixed. In the case of townships of the second class, the township seal may be affixed with the certifying official's signature in lieu of notarization when this action has been approved by the township supervisors.
SUBMIT 3 COPIES OF THE COMPLETED APPLICATION WITH ORIGINAL SIGNATURES AND EMBOSSED SEALS, AND 1 COPY OF ACTIVITY RECORDS, INVOICES, PROOF OF PAYMENT AND MUNICIPAL ORDINANCES. KEEP A COPY FOR YOUR RECORDS.
IF REIMBURSEMENT OF SMP EXPENSES IS NOT REQUESTED, SECTIONS A, G AND H STILL MUST BE COMPLETED AND SUBMITTED.
COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES
FOR SEWAGE MANAGEMENT PROGRAM (SMP) ADMINISTRATION
UNDER THE PENNSYLVANIA SEWAGE FACILITIES ACT
AND SMP ANNUAL REPORT


 
FOR APPLICATION YEAR ENDING December 31, 20
  
READ ALL INSTRUCTIONS BEFORE COMPLETING. APPLICATION MUST BE RECEIVED BY THE DEPARTMENT OF ENVIRONMENTAL PROTECTION (DEP) NO LATER THAN MARCH 1 FOR ALL DUTIES PERFORMED FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR.
SECTION A
1.   Applicant (Municipality)

     

2.   Name and Title of Municipal Official

     

E-Mail Address (Optional)
     

3.   Daytime Telephone Number

     

4.   County

     

5.   Federal I.D. No.

     

6.   Address

     

7   City   Zip

             

8.   Name of Authorized Local Agency (LA) or County Health Department

     

SECTION B - REIMBURSEMENT REQUEST
1.   TOTAL EXPENSES $                
2.   NET REVENUE $                
3.   PROGRAM DEFICIT

  (subtract 2 from 1)

$                
4.   REIMBURSEMENT REQUESTED

  (This is the program deficit, shown on Line 3, but not more than 50% or 85% of the total expenses shown on Line 1, according to the LA's reimbursement level, Item 8, above.)

$                
     
DEP USE ONLY
5.   Reviewer's Initials and Approval Date
 

              /           /            


Submit your application in triplicate, 1 copy of supporting documentation (if requesting reimbursement) no later than March 1, 2018 to:
 
Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P.O. Box 8774
Harrisburg, PA 17105-8774

SECTION C - ITEMIZED EXPENSES
Copies of activity records or itemized invoices and proof of payment for these expenses must be submitted.
COST OBJECT
AMOUNT
OBJECT TOTAL
Municipal/LA Personnel Expenses
$       
             
             
             
             
            $      
Administrative & Clerical Expenses    
             
             
             
             
            $      
Inspection Services    
             
             
             
             
            $      
Consultant Services    
             
             
             
             
            $      
Materials & Supplies        
             
             
             
             
            $        


COST OBJECT
AMOUNT
OBJECT TOTAL
Legal Services
   
             
         
         
        $      
Auto Expense       miles @       ¢/mile    
             
         
         
        $      
Social Security and Medicare Expenses    
             
             
             
            $      
Other Expenses    
             
             
             
            $      
 
Total Expenses:
$       
Enter Total Expenses in Section B.1.
NOTE: Expenses are subject to audit by DEP or its authorized representative.
 

SECTION D - REVENUE
   
1.   Total Revenue from Inspection Fees $        
2.   Other Money Received - specify, i.e., assessments, money from other agencies or departments
$       
3.   Fines, interest, etc.
$       
4.   Uncollected Revenue - specify, i.e., Accounts Receivable, to include unpaid fines and assessments
$         
Total Revenue $         
Less Refunds $        
Net Revenue $          
 Enter Net Revenue in Section B.2.

 

SECTION E - SCHEDULE OF INSPECTION FEES AND FINES
 
Standard Fees/Charges to Municipality or LA by Contracted Inspectors (If Applicable)
Standard Fees/Fines to Property Owners (Municipal or LA Income)*
 
   
Residential
Other
 
Residential
Other
 
Type of Activity:
             
Pumping/Inspection Notice Sent
 
     
                     
Fine for Failure to Report  
     
                     
Liens Placed  
     
                     
Eviction Notices Served  
     
                     
Cesspools Inspection
     
                     
Inground Gravity Bed Inspection
     
                     
Inground Pressure Dosed Bed Inspection
     
                     
Sand Mound Non-Pressure Dosed Inspection
     
                     
Sand Mound Pressure Dosed Inspection
     
                     
Individual Residential Spray Irrigation System (IRSIS) Inspection
     
                     
Small Flow Spray Pre-IRSIS Inspection
     
                     
Small Flow Stream Discharge Inspection
     
                     
Large Volume Community Onlot Inspection
     
                     
Spray > 2000 gallons per day (gpd) Inspection
     
                     
Other Non-Municipally Owned Sewage Treatment Plants Inspection
     
                     
Non-Municipally Owned Pump Stations, Lift Stations, etc. Inspection
     
                     
Other (List & Identify)            
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     
           
     
                     

* This section must be consistent with the LA's current fee schedule.

 

SECTION F - ACTIVITY RECORD FOR ADMINISTRATION OF

PENNSYLVANIA SMPs UNDER THE ACT

Activity Report for           SEO   SECY   Other        
  Name   Position

Salaried   Flat Hourly Rate           Mileage Rate         ¢

Date
Description of Activity
A.

Total Time Spent in Hours

B.

Fee Charged (Contracted Services Only)

C.

Personal Auto Miles Claimed

D.

Description of Equipment & Supplies Purchased

E.

Cost of Equipment & Supplies (Invoice Required)

                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
                                         
TOTAL THIS PAGE
                             
Hourly Employees – Total Hours (A) x Hourly Rate = Total Employee Cost $     
Contracted Services – Total Fees Charged (B) – Invoices Required $     
Salaried Employees – Total Hours (A) on SMP ÷ Total Annual

Hours           x Annual Salary & Benefits           = Total Employee Cost

$     
All Employees – Total Personal Miles (C) x Mileage Rate = Total Vehicle Cost $     
All Employees – Total Cost of Equipment & Supplies Purchased x (E) - Invoices Required $     
  TOTAL COST TO SMP $       
This activity record or its equivalent must be used to track SMP time spent by salaried employees. The municipality or LA may also require contracted individuals to submit this activity record or its equivalent, in addition to the required invoices. Invoices must be provided for any items purchased and services contracted.
 
       
  Period Covered

 

Completion of Section G is Required

Date of approval of the Official Plan approving the SMP (See page 1, paragraph 1)        

Status of the approved SMP (choose one)

Implemented

Under active development
Not implemented
 

SECTION G - SUMMARY OF SMP ACTIVITY

FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR

 
A.
 
 
 
 
Number of Systems in Each Category in SMP*
B.
 
Operation and Maintenance
(O & M) Educational Materials Sent to Property Owners
C.
 
 
 
 
Number of Pumping/ Maintenance Requirement Notices Sent
D.
 
 
Number of Pumping Receipts/ Maintenance Receipts Received
E.
 
 
 
 
 
Number of Municipal Inspections Performed**
F.
 
 
Enforcement Actions Taken in Response to Inspections or to Property Owner's Refusal to Comply with SMP Requirements
  1.   Aerobic Treatment Tank
               
  2.   Septic Tank                
TOTAL
             
How many of the systems in your management area use the following means of disposal? Please enter program activity as it relates to systems having methods of disposal listed below.
 
A.
B.
C.
D.
E.
F.
  1.   Holding Tanks
     
     
     
     
     
     
  2.   Cesspools
     
     
     
     
     
     
  3.   Gravity Inground Bed/Trench
     
     
     
     
     
     
  4.   Pressure Dosed Inground Bed/ Trench
     
     
     
     
     
     
  5.   Non-Pressure Dosed Elevated Sand Mound
     
     
     
     
     
     
  6.   Pressure Dosed Elevated Sand Mound/Trench
     
     
     
     
     
     
  7.   IRSIS
     
     
     
     
     
     
  8.   Pre-IRSIS Small Flow Spray
     
     
     
     
     
     
  9.   Small Flow Stream Discharge
     
     
     
     
     
     
  10.   Large Volume Community Onlot
     
     
     
     
     
     
  11.   Spray > 2000 gpd
     
     
     
     
     
     
  12.   Other Non-Municipally Owned Sewage Treatment Plants
     
     
     
     
     
     
  13.   Non-Municipally Owned Pump Stations, Lift Stations, etc.
     
     
     
     
     
     
  14.   Other (List & Identify)     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
TOTAL
     
     
     
     
     
     
 

 

*  Information requested in Column A is for the total number of systems included in the SMP. Information requested in Columns B through F is for related SMP activity during the preceding year.
**  Inspections performed by a consulting firm employed by the municipality or LA must also be included in Column E.


 

SECTION H - AFFIDAVIT
Affidavit must be completed and signed before a notary public by the municipal/LA official named in Section A.4. In the case of townships of the second class, the township seal may be affixed hereto with the official's signature in lieu of the seal of a notary public. Is applicant a second class township?     Yes     No
 
 
 
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF        
 
I,         ,   being duly sworn according to law, depose and say that I am an official of the applicant and that the information included in the application and documents submitted as a part of the application are true and correct to the best of my knowledge and belief.
 
Sworn to and subscribed before me this           day of         ,   20      .
 
     
  Signature of Notary Public   Signature of LA Official
 
MY COMMISSION EXPIRES                  
      Title
 
SEAL
 
 

 
 
 
 
 

SMP
REIMBURSEMENT APPLICATION
CHECKLIST

 
 
A completed application for SMP reimbursement consists of:
 
1.   Three copies of this completed application with original signatures and embossed seals.
 
2.   One copy of activity records and/or invoices for all expenses claimed.
 
3.   One copy of cancelled checks (both sides), W-2 forms and/or payroll records for all expenses claimed.
 
4.   One copy of report of revenue listed in Section D.
 
5.   One copy of all municipal ordinances, acts, regulations, or procedures used in administrating the applicant's SMP, for first time applications. Subsequent submissions must include a copy of any additions, deletions and amendments made during the preceding year to municipal ordinances, acts or procedures that affect the SMP.
 

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