OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program For Partnerships Business Profile:

Name of applicant firm:______________________________________________________________________

Name of Managing Partner:__________________________________________________________________

EIN:___________________ Social Security Number _________________ E mail Address:_______________

Business Address:______________________________________________ County:______________________

City:_________________________________ State:_______________ Zip Code:________________________

Phone Number:___________________________ Fax Number:______________________________________

Mailing Address ( if different than above):_________________________ County:_____________________

City:_________________________________ State:_______________ Zip Code:________________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? ____________

Are you claiming disabled status? ____ Yes ____ No ( i. e., a United States citizen who has permanent or temporary physical or mental impairment that substantially limits one or more of your major life activities.) If yes, please submit documentation substantiating such disability.

Is your firm at least 51% owned by a Disabled American? ____ Yes ____ No.

Is your firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide PRO Net number: ______________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide PRO Net number: ____________________________________

Is your firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ______________________________________________________

Is your firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity: ____________________________________________________________________________________

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 1 Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy of the prior determination of attempts to obtain certification: ____________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Does your firm have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc.? ___ Yes ___ No. If yes, provide State( s) and ID number( s): _______________________________________

In accordance with 13 CFR § 124.103, designated group members are presumed to be socially disadvantaged. Designated group members are individuals who hold themselves out to be and are identified by others as Black Americans, Native Americans ( American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small Business Administration ( SBA). If an individual is claiming to be a member of a designated group, complete Section A of this application. If an individual is not claiming to be a member of a designated group, complete Section B of this application. All applicants must complete Sections C, D, and E of this application.

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 2 SECTION A Eligibility Statement  Designated Group Members Social Disadvantage 1. Is your firm at least 51% owned by a U. S. citizen? ____ Yes ____ No. If your firm is not at least 51% owned by a U. S. Citizen, stop here. You are not eligible to participate as a DBE under EPA's DBE Certification Program.

2. List all individuals claiming disadvantaged status.

Name of Individual Group U. S. Citizen Other Last Place of Sex Membership Y/ N Names Used Birth M/ F __________________________ ___________ ________ ___________ _______ _____

__________________________ ___________ ________ ___________ _______ _____

__________________________ ___________ ________ ___________ _______ _____

2a. If you are a naturalized Citizen, please provide the following as Attachment A 1: ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

SECTION B Eligibility Statement   Non Designated Group Members 1. List all individuals claiming disadvantaged status:

Name of Individual U. S. Citizen Race Sex Y/ N M/ F _______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

1a. If you are a naturalized Citizen, please provide the following as Attachment B 1: naturalization number; ( b) date of citizenship; and ( c) county, state and court.

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 3 For this section, all individuals claiming social disadvantage must provide a separate response for questions 3 and 4.

Social Disadvantage 2. I, ____________________________________ have personally suffered social disadvantage based on my identification as __________________________________. ( A claim of social disadvantage must include at least one objective feature that has contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, long term residence in an environment isolated from the mainstream of American society, or other similar causes not common to individuals who are not socially disadvantaged.)

3. Document how your ability to compete in the free enterprise system has been impaired by such things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or leases; restriction of your market to certain racial, ethnic or social groups; underemployment or unemployment, etc., as compared to others in the same or similar line of business who are not socially disadvantaged. Provide as Attachment B 2.

4. Attach a narrative describing how you personally experienced social disadvantage in American society. When writing your narrative, be as specific and detailed as possible. Where applicable, each statement of alleged discrimination should be supported by documented evidence such as affidavits, denials of loan applications, denials of employment opportunities ( including non selection for particular jobs, denials of promotions, or unequal work environment or treatment), and documents to support any formal action taken by you because of alleged discrimination. You must demonstrate how your identification, as described in the paragraph above, has negatively impacted your entry into or advancement in business. You must address disadvantage in education, employment, and business history, where applicable. Examples of discrimination include, but are not limited to: unequal access to colleges or professional schools; exclusion from professional or business associations; being denied educational honors or recognition; experiencing discriminatory social pressure which discouraged you from pursuing a professional or higher education or forced you into non professional or non business fields; discrimination in employment opportunities or pay and fringe benefits; unequal access to business credit or capital; and discrimination in the awarding, bidding process, or negotiating of government or private sector contracts. Provide as Attachment B 3.

SECTION C ( All applicant firms must complete)

Economic Disadvantage 1. Is the net worth of each individual( s) claiming disadvantaged status less than $ 750,000, excluding ownership interest in the applicant firm and equity in the individual( s) primary residence? ____ Yes ____ No.

2. For individual( s) claiming disadvantaged status, list your personal net worth, excluding the ownership interest in the applicant firm and the equity in the individual( s) primary residence.

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 4 Name Average 2 year Personal Total Income Net Worth Assets ________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

3. Each individual listed in number 2 above, certifies that because of racial and/ or ethnic prejudice, and/ or cultural bias, my ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business that are not socially disadvantaged.

SECTION D ( All applicant firms must complete)

Ownership 1. Provide the name, title, and percentage of ownership ( class, if applicable) for each partner of the firm. Does the partnership agreement reflect the ownership of each partner? ____ Yes ____ No.

Name Title Ownership Percentage ______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

______________________ ____________________ ___________________________

2. Has there been any changes in ownership in the last year? ____ Yes ____ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment D 1.

3. For community property residents only. If you are a married disadvantaged owner, and your spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a majority interest in the business as Attachment D 2.

Name of Disadvantaged Partner State Percent Transferred ______________________ ____________________ _____________________

______________________ ____________________ _____________________

______________________ ____________________ _____________________

______________________ ____________________ _____________________

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 5 4. Has any individual( s) claiming disadvantaged status transferred any assets within two years, in full or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes, provide the following information as Attachment D 3: the date of transfer; to whom the assets were transferred; amount paid for the assets; and the market value of the assets at the time of transfer. Individuals may exclude assets transferred to an immediate family member that are consistent with the customary recognition of special occasions, such as birthdays, graduations, anniversaries and retirements. Individuals may also exclude any transfers to an immediate family member if for educational, medical or essential support purposes.

SECTION E ( All applicant firms must complete)

Control 1. List the name( s) of all Partners:

Name Limited/ General ___________________________________ _____________________________

___________________________________ _____________________________

___________________________________ _____________________________

___________________________________ _____________________________

2. Are partnership decisions determined by general partners? If no, explain as Attachment E 1.

3. Is a general partner, or any disadvantaged full time manager engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain as Attachment E 2.

4. Have any of the nondisadvantaged individuals involved in the management of the applicant firm, partners, or their immediate family members, had a prior business relationship with any individual claiming disadvantage status? This includes such relationships as employer employee, supervisoremployee co workers, investor employee, etc. ___ Yes ___ No. If yes, identify the person( s) and the type of business relationship as Attachment E 3.

5. List the total compensation from the applicant firm of all partners and/ or key managers of the firm. ( If necessary, provide additional information as Attachment E 4).

Name/ Title Compensation from applicant firm ( includes salaries, bonuses, etc.)

_________________________________ ___________________________________

________________________________ ___________________________________

________________________________ ___________________________________

________________________________ ___________________________________

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 6 6. Does the applicant firm operate in an industry which requires bonding or professional licenses? ___ Yes ___ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm as Attachment E 5.

7. List the names of all individuals who have access to the firm's bank account.

Name Title ______________________________ _____________________________

______________________________ _____________________________

______________________________ _____________________________

8. Does any individual( s), ( other than the individual( s) claiming disadvantaged status) or entities provide:

a) Financial support to the applicant firm? ___ Yes ___ No b) Subcontracts, Joint Ventures or Teaming Arrangements? ___ Yes ___ No c) Office space ( rent or leased). ___ Yes ___ No d) Equipment ( rent or leased). ___ Yes ___ No e) Employees ( other than from employment agencies). ___ Yes ___ No f) Provide business bank account. ___ Yes ___ No If you answered yes to any of the above, please provide specific details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment E 6.

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 7 Each person signing below:

1. Certifies that the information provided with regard to my social and economic disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

2. Certifies that the information provided with regard to my ownership and control status is true, accurate and complete to the best of my knowledge and belief.

3. Certifies that the information provided with regard to my status as a United States citizen is true, accurate and complete to the best of my knowledge and belief.

4. Certifies that the information provided with regard to my individual disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

5. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate and complete to the best of my knowledge and belief.

6. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state and local agencies for determining violations of law.

7. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001 , which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 8 available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1c) ( Partnerships) 9 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program Alaska Native Corporation ( ANC) Owned Concern Name of Alaska Native Corporation ( ANC): _______________________________________________

Address of ANC: ______________________________________________________________________

Name of President/ CEO: __________________________________

EIN: _________________________ E mail Address:_________________________________________

Business Address:______________________________________________ County:_______________

City:_________________________________ State:_______________ Zip Code:__________________

Phone Number:___________________________ Fax Number:________________________________

Mailing Address ( if different than above):________________________ County:_________________

City:_________________________________ State:_______________ Zip Code:__________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? _____________________________________________________________________________________

Is your firm certified by the Small Business Administration under its 8( a) Business Development Program?___ Yes ___ No. If yes, provide Pro Net number: _________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide Pro Net number: ____________________

Is your firm certified as a DBE by a U. S. Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ________________________________________________

Is your firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and the certifying entity: ________________________________________________________________________________

Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanation/ documentation:__________________________________________________ _____________________________________________________________________________________

EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) Do you have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ________________________________

Is the applicant ANC business corporation a for profit corporation? ___ Yes ___ No.

EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) 2 Business Eligibility SECTION A Social Disadvantage 1. An Alaska Native Corporation that that meets the following criteria is considered socially disadvantaged:

Alaska Native Corporation or ANC means any Regional Corporation, Village Corporation, Urban Corporation, or Group Corporation organized under the laws of the State of Alaska in accordance with the Alaska Native Claims Settlement Act, as amended ( 43 U. S. C. 1601, et seq.).

Provide documentation that the applicant entity meets these criteria as Attachment A 1.

SECTION B Economic Disadvantage 1. Do Alaska Natives and descendants of Natives own a majority of both the total equity of the ANC and the total voting powers to elect directors of the ANC through their holdings of settlement common stock? ___ Yes ___ No. If yes, provide verification of the percentage of Alaska Native ownership as attachment B 1.

SECTION C Ownership 1. Does the ANC and holders of its settlement common stock own at least 51% interest in the ANC? Please provide documentation as attachment C 1.

2. If more than one class of stock, provide information for each class: Voting Non Total Voting a) Total number of shares authorized: _____ ______ _____ b) Total number of shares currently outstanding: _____ ______ _____

3. List all entities, individuals, and/ or trusts that have an ownership interest in the applicant firm. Name Title Ownership Percent Voting Non voting Total ___________________________ ____________________ ______ _________ ______

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) 3 4. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment C 2.

SECTION D Control and Management 1. Are the management and daily business operations of the applicant firm controlled by the ANC through one or more disadvantaged individual members who possess sufficient management experience of an extent and complexity to run the concern? ___ Yes ___ No. If yes, provide documentation to verify tribal membership and management competency as Attachment D 1.

2. Are members of the management team, business committee members, officers, and directors engaged in any outside employment or other business interests which conflict with the management of the applicant firm? ___ Yes ___ No.

3. List the titles of all officers, directors, management members, partners and key managers and the hours devoted, by such individual( s) to the management of the applicant firm.

Name Title Hours ____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

4. List the names of all individuals who have access to the firm's bank account.

Name Title ___________________________ __________________________

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) 4 Each person signing below:

1. Certifies that the applicant firm is at least 51% owned and controlled by an Alaska Native Corporation ( ANC).

2. Certifies that the information provided with regard to the applicant firm's economic disadvantaged status is true, accurate, and complete to the best of his/ her knowledge and belief.

3. Certifies that the information provided with regard to the applicant firm's ownership and control status is true, accurate, and complete to the best of his/ her knowledge and belief.

4. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate, and complete to the best of his/ her knowledge and belief.

5. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state and local agencies to determine violations of law.

6. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001 , which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) 5 ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1e) ( Alaska Native Corporations) 6 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program Community Development Corporation ( CDC) Owned Concern Name of Parent Community Development Corporation ( CDC): _________________________________________________________________________________

Address of Parent CDC: _____________________________________________________________

Name of wholly owned subsidiary ( if applicable): _______________________________________

Address of wholly owned subsidiary: _________________________________________________

Name of applicant firm: _________________________________________________________________________________

Applicant concern is:  Corporation  Limited Liability Company  Partnership Name of President/ Managing Member/ Managing Partner: ________________________________

EIN: _______________________ E mail Address: _______________________________________

Business Address: ___________________________________________ County: _______________

City: _______________________________ State: _______________ Zip Code: ________________

Phone Number: __________________________ Fax Number: ______________________________

Mailing Address ( if different than above): _______________________ County: ________________

City: _______________________________ State: _______________ Zip Code: ________________

What is the firm's ( 4 digit) primary standard industrial classification code? __________________

Is the firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide Pro Net number________________________________

Is the firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide Pro Net number____________________

Is the firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s) ___________________________________________________

Is the firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity ____________________________________________________________

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanation/ documentation: _____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Does the firm have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc? ___ Yes ___ No. If yes, provide the State( s) and ID number( s)__________________ __________________________________________________________________________________

SECTION A Eligibility Statement Social and Economic Disadvantage 1. A Community Development Corporation ( CDC) is considered to be a socially and economically disadvantaged entity if the parent CDC is a nonprofit organization responsible to residents of the area it serves which has received financial assistance under 42 U. S. C. 9805, et seq.

Does the parent CDC of the applicant concern meet this criteria? ___ Yes ___ No. If yes, provide evidence of nonprofit organization and documentation of assistance as Attachment A 1.

SECTION B Ownership 1. Is the applicant concern at least 51 percent owned by a CDC or a wholly owned business entity of a CDC? ____ Yes ____ No. If yes, please provide evidence of ownership as Attachment B 1.

Corporations Only:

2. If more than one class of stock, provide information for each class: Voting Non Total Voting a) Total number of shares authorized: _____ ______ _____ b) Total number of shares currently outstanding: _____ ______ _____

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 2 Limited Liability Companies Only:

3. If more than one class membership interest, provide information for each class: Voting Non Total Voting a) Total number of memberships authorized: _____ ______ _____ b) Total number of memberships currently outstanding: _____ ______ _____

Partnerships Only:

4. Provide the name, title, and percentage of ownership for each partner of the firm. Does the partnership agreement reflect the ownership of each partner? ___ Yes ___ No.

Name Title Ownership %

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

Questions 5 through 9 are for Corporations & LLCs ONLY:

5. List all entities, individuals, and/ or trusts which have an ownership interest in the applicant firm.

Name Title Ownership % Voting NonVoting Total ___________________________ ____________________ ______ _________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

6. Does the parent CDC or its wholly owned subsidiary receive at least 51% of the annual distributions of dividends paid on the stock of a corporate applicant firm? ___ Yes ___ No. If no, please explain as Attachment B 2.

7. Will the parent CDC or its wholly owned subsidiary receive 100% of the unencumbered value of each share of stock owned in the event that the stock is sold? ___ Yes ___ No. If no, please explain as Attachment B 3.

8. If the corporation dissolves, will the parent CDC or its wholly owned subsidiary receive at least 51% of the retained earnings and 100% of the unencumbered value of each share of stock owned? ___ Yes ___ No. If no, please explain as Attachment B 4.

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 3 9. Is ownership by the parent CDC or its wholly owned subsidiary subject to conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements, or other similar arrangements which may impact the unconditional ownership of the CDC? ___ Yes ___ No. If yes, explain as Attachment B 5.

Corporations, LLCs & Partnerships:

10. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment B 6.

SECTION C Control and Management 1. List all individuals who manage or conduct daily business operations of the applicant concern.

Name/ Title Date ___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

2. Are any of the individuals listed in question 1 engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain as Attachment C 1.

3. List the total compensation from the applicant firm of all owners and/ or key managers of the firm. ( If necessary, provide additional information as Attachment C 2).

Name/ Title Compensation from applicant firm ( Include salaries, bonuses, etc.)

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

4. Does the applicant firm operate in an industry which requires bonding or professional licenses? ___ Yes ___ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm on Attachment C 3.

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 4 5. List the names of all individuals who have access to the firm's bank account.

Name Title ___________________________________ _________________________________

___________________________________ _________________________________

___________________________________ __________________________________

___________________________________ __________________________________

6. Does any individual( s), or entities provide:

a) Financial support to the applicant firm? ___ Yes ___ No b) Subcontracts, Joint Ventures, or Teaming Arrangements? ___ Yes ___ No c) Office space ( rent or leased). ___ Yes ___ No d) Equipment ( rent or leased). ___ Yes ___ No e) Employees ( other than from employment agencies). ___ Yes ___ No If the answer is yes to any of the above, please provide specific details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment C 4.

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 5 Each person signing below:

1. Certifies that the information provided with regard to the applicant firm's social and economic disadvantaged status is true, accurate, and complete to the best of his/ her knowledge and belief.

2. Certifies that the information provided with regard to the applicant firm's ownership and control status is true, accurate, and complete to the best of his/ her knowledge and belief.

3. Certifies that the information provided with regard to his/ her individual disadvantaged status is true, accurate, and complete to the best of his/ her knowledge and belief.

4. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate, and complete to the best of his/ her knowledge and belief.

5. Acknowledges that the EPA, at its discretion, may give the information submitted to Federal, State, and local agencies to determine violations of law.

6. Acknowledges that the EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting and record keeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose, or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001 , which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays.

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 6 The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1i) ( Community Development Corporation ( CDC) Owned Concern) 7 OMB Control No: ____ Approved: ____ Approval Expires: ____

Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program For Corporations Business Profile:

Name of applicant firm: ____________________________________________________

Name of President/ Chief Executive Officer: ____________________________________________________ EIN:_______________________________________ E mail Address:________________________________

Business Address:________________________________ County:__________________________________

City:_______________________________ State: _________ Zip Code:_______________________________

Phone Number:____________________________ Fax Number: _________________________

Mailing Address ( if different than above):_________________________ County:_______________________

City:_________________________________ State:_______________ Zip Code:_______________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? ______________

Are you claiming disabled status? ___ Yes ___ No. ( i. e., a United States citizen who has permanent or temporary physical or mental impairment that substantially limits one or more of your major life activities). If yes, please submit documentation substantiating such disability.

Is your firm at least 51% owned by a Disabled American? ___ Yes ___ No.

Is your firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide PRO Net number: ______________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide PRO Net number: _______________________________________

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) Is your firm certified as a DBE by a U. S. Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ____________________________________________________

Is your firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number the certifying entity: ____________________________________________________ Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No If yes, provide a copy of the prior determination of attempts to obtain certification: _____________________________________ ____________________________________________________

Do you have any other certification as a disadvantaged business entity, i. e, MBE, DBE, WBE, etc? ___ Yes ___ No. If yes, provide State( s) and ID number( s) ________________________________________

In accordance with 13 CFR § 124.103, designated group members are presumed to be socially disadvantaged. Designated group members are individuals who hold themselves out to be and are identified by others as Black Americans, Native Americans ( American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small Business Administration ( SBA). If an individual is claiming to be a member of a designated group, complete Section A of this application. If an individual is not claiming to be a member of a designated group, complete Section B of this application. All applicants must complete Sections C, D, and E of this application.

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 2 SECTION A Eligibility Statement  Designated Group Members Social Disadvantage 1. Is your firm at least 51% owned by a U. S. citizen? ___ Yes ___ No. If your firm is not at least 51% owned by a U. S. citizen, stop here. You are not eligible to participate as a DBE under EPA's DBE Certification Program.

2. List all individuals claiming disadvantaged status:

Name of Individual Other last U. S. Citizen Place of Group Sex Names Used Y/ N Birth Membership M/ F ___________________ ___________ ________ ___________ _______ _____

a) If you are a naturalized citizen, please provide the following as Attachment A 1, ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

SECTION B Eligibility Statement  Non Designated Group Members 1. List all individuals claiming disadvantaged status:

Name of Individual U. S. Citizen Race Sex Y/ N M/ F _______________________________ ________ ________ _____

a) If you are a naturalized citizen, please provide the following as Attachment B 1, ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

For this section, any individual claiming social disadvantage must provide a separate response for questions 3 and 4.

Social Disadvantage 2. I, ____________________________________ have personally suffered social disadvantage based on my identification as __________________________________. ( A claim of social disadvantage must include at least one objective feature that has contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, long term residence in an environment isolated from the mainstream of American society, or other similar causes not common to individuals who are not socially disadvantaged.)

3. Document how your ability to compete in the free enterprise system has been impaired by such things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or leases; restriction of your market to certain racial, ethnic or social groups; underemployment or EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 3 unemployment, etc., as compared to others in the same or similar line of business who are not socially disadvantaged. Provide as Attachment B 2.

4. Attach a narrative describing how you personally experienced social disadvantage in American society. When writing your narrative, be as specific and detailed as possible. Where applicable, each statement of alleged discrimination should be supported by documented evidence such as affidavits, denials of loan applications, denials of employment opportunities ( including non selection for particular jobs, denials of promotions, or unequal work environment or treatment), and documents to support any formal action taken by you because of alleged discrimination. You must demonstrate how your identification, as described in the paragraph above, has negatively impacted your entry into or advancement in business. You must address disadvantage in education, employment, and business history, where applicable. Examples of discrimination include, but are not limited to: unequal access to colleges or professional schools; exclusion from professional or business associations; being denied educational honors or recognition; experiencing discriminatory social pressure which discouraged you from pursuing a professional or higher education or forced you into non professional or non business fields; discrimination in employment opportunities or pay and fringe benefits; unequal access to business credit or capital; and discrimination in the awarding, bidding process, or negotiating of government or private sector contracts. Provide as Attachment B 3.

SECTION C ( All applicant firms must complete)

Economic Disadvantage 1. Is the net worth of each individual( s) claiming disadvantaged status less than $ 750,000, excluding ownership interest in the applicant corporation and equity in the individual( s) primary residence? ____ Yes ____ No.

2. For individual( s) claiming disadvantaged status, list your personal net worth, excluding the ownership interest in the applicant corporation and the equity in the individual( s) primary residence.

Name Average 2 year Personal Total Income Net Worth Assets ________________________________ ______________ __________ _______

3. Have any individual( s) listed in number 2 above transferred any assets within two years, in full or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes, provide the following information as Attachment C 1: the date of transfer; to whom the assets were transferred; amount paid for the assets; and the market value of the assets at the time of transfer. Individual( s) may exclude assets transferred to an immediate family member that are consistent with the customary recognition of special occasions, such as birthdays, graduations, anniversaries and retirements. Individual( s) may also exclude any transfers to an immediate family member if for educational, medical or essential support purposes.

4. Each individual listed in number 2 above, certifies that because of racial and/ or ethnic prejudice, and/ or cultural bias, his/ her ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business that are not socially disadvantaged.

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 4 SECTION D ( All applicant firms must complete)

Ownership 1. If more than one class of stock, provide information for each class: Voting Non Total Voting a) Total number of shares authorized: _____ ______ _____ b) Total number of shares currently outstanding: _____ ______ _____

2. List all individuals, entities, and/ or trusts, which have an ownership interest in the applicant firm.

Name Title Voting Ownership Percentage Non Voting Total ________________ ______ _____ ____________ __________

3. Do disadvantaged individuals receive at least 51% of the annual distributions of dividends paid on the stock of a corporate applicant firm? ___ Yes ___ No. If no, please explain and provide as Attachment D 1.

4. Do disadvantaged individuals own 51% or more of each class of voting stock outstanding and 51% of the aggregate of all stock outstanding? ___ Yes ___ No.

5. Will disadvantaged individuals receive 100% of the unencumbered value of each share of stock owned in the event that the stock is sold? ___ Yes ___ No. If no, please explain and provide as Attachment D 2.

6. If the corporation dissolves, will disadvantaged individuals receive at least 51% of the retained earnings and 100% of the unencumbered value of each share of stock he or she owns? ___ Yes ___ No. If no, please explain and provide as Attachment D 3.

7. Is ownership by any individual claiming disadvantaged status subject to conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar arrangements, which may impact the unconditional ownership of such individuals? ___ Yes ___ No. If yes, explain as Attachment D 4.

8. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did the change in ownership affect the disadvantaged status of your firm? Please explain as Attachment D 5.

For community property residents only. If you are a married disadvantaged owner, and your spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a majority interest in the business.

Name of Disadvantaged Owner State of Residence Percent Transferred ____________________________ ____________ __________________

SECTION E EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 5 ( All applicant firms must complete)

Control 1. Disadvantaged individuals control the board of directors by virtue of the fact that ( select only one below): ____ a) A single disadvantaged individual owns 100% of all the voting stock of the applicant business.

____ b) A single disadvantaged individual owns at least 51% of all voting stock, is on the Board of Directors, and no super majority voting requirements exist for shareholders to approve corporate actions.

____ c) A single disadvantaged individual owns at least 51% of all voting stock, is on the Board of Directors, and owns at least the percentage of voting stock needed to overcome the super majority voting requirements which exist for shareholders to approve corporate actions.

____ d) More than one disadvantaged individual owns at least 51% of all voting stock, all such individuals serve on the Board of Directors, no super majority voting requirements exist for shareholders to approve corporation actions, and the disadvantaged shareholders can demonstrate they have made enforceable arrangements to permit one of them to vote the stock of all as a block without holding a shareholder meeting. ____ e) More than one disadvantaged individual owns at least 51% of all voting stock, all such individuals serve on the Board of Directors, in total all own at least the percentage of voting stock needed to overcome the existing super majority voting requirements which exist for shareholders to approve corporate actions, and the disadvantaged individuals can demonstrate they have made enforceable arrangements to permit one of them to vote the stock of all as a block without holding a shareholder meeting.

OR ____ f) The disadvantaged individual( s) control the Board of Directors through actual numbers of voting directors.

____ g) The disadvantaged individual( s) control the Board of Directors through weighted voting and such voting is permitted by applicable state law.

2. List the titles of all officers, directors, and key managers and the hours devoted by such individuals to the management of the applicant business.

Name Title Hours _____________________ __________ _______

3. Is the CEO, President or any disadvantaged full time manager engaged in or planning to engage in outside employment? ___ Yes ___ No. If yes, provide details as to the extent of outside employment or other business dealings including daily hours of employment, location and explanation as to how this outside employment does not conflict with the ability to manage and control the daily operations of the applicant concern, provide as Attachment E 1.

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 6 4. Have any of the nondisadvantaged individuals involved in the management of the applicant firm, and/ or stockholders, officers, directors or their immediate family members, had a prior business relationship with any individual claiming disadvantaged status? This includes such relationships as employer employee, supervisor employee, co workers, investor employee, etc. ___ Yes ___ No. If yes, identify the person( s) and the type of business relationship, provide as Attachment E 2.

5. Does any nondisadvantaged individual receive compensation in any form, including dividends, as a director, officer, or employee that exceeds the compensation received by the disadvantaged President or CEO? ____ Yes ____ No. If yes, provide the total compensation received by the President or CEO, and the name( s) and the amount of the total compensation paid to the nondisadvantaged individual( s). If any nondisadvantaged individual is more highly compensated, provide a statement that justifies the need for the nondisadvantaged individual( s) to receive a higher compensation, provide as Attachment E 3.

6. Does the applicant firm operate in an industry that requires bonding or professional licenses? ___ Yes ___ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm, provide as Attachment E 4.

7. List the names and titles of all individuals who have access to the firm's bank account.

Name Title ________________________ _______________________

8. Do any individual, ( other than the individual( s) claiming disadvantaged status) or entities provide:

a) Financial support to the applicant firm ___ Yes ___ No b) Subcontracts, Joint Ventures or Teaming Arrangements ___ Yes ___ No c) Office space ( rent or leased) ___ Yes ___ No d) Equipment ( rent or leased) ___ Yes ___ No e) Employees ( other than from employment agencies) ___ Yes ___ No If you answered yes to any of the above, please provide specific details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements, provide as Attachment E 5.

Each person signing below:

1. Certifies that the information provided with regard to my social and economic disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

2. Certifies that the information provided with regard to my ownership and control status is true, accurate and complete to the best of my knowledge and belief.

3. Certifies that the information provided with regard to my status as a United States citizen is true, accurate and complete to the best of my knowledge and belief.

4. Certifies that the information provided with regard to my individual disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

5. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate and complete to the best of my knowledge and belief.

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 7 6. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state and local agencies to determine violations of law.

7. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ _______________________ ______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001, which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1d) ( Corporations) 8 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program For Limited Liability Company Business Profile:

Name of applicant firm:___________________________________________________________________

Name of Managing Members and Titles:_____________________________________________________

EIN:_________________________ E mail Address:_____________________________________________

Business Address:______________________________________________ County:___________________

City:_________________________________ State:_______________ Zip Code:______________________

Phone Number:___________________________ Fax Number:___________________________________

Mailing Address ( if different than above):_________________________ County:___________________

City:_________________________________ State:_______________ Zip Code:______________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? _________

Are you claiming disabled status? ___ Yes ___ No. ( i. e., a United States citizen who has permanent or temporary physical or mental impairment that substantially limits one or more of your major life activities.) If yes, please submit documentation substantiating such disability.

Is your firm at least 51% owned by a Disabled American? ___ Yes ___ No.

Is your firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide PRO Net number: ___________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide PRO Net number: _________________________________

Is your firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ____________________________________________________________

Is your firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity: ______________________________________________________________________________________

Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy of the prior determination of attempts to obtain certification: ______________________________________

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) ___________________________________________________________________________ Does your firm have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc.? ____ Yes ___ No. If yes, provide State( s) and ID number( s) _______________________________________

In accordance with 13 CFR § 124.103, designated group members are presumed to be socially disadvantaged. Designated group members are individuals who hold themselves out to be and are identified by others as Black Americans, Native Americans ( American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small Business Administration ( SBA). If an individual is claiming to be a member of a designated group, complete Section A of this application. If an individual is not claiming to be a member of a designated group, complete Section B of this application. All applicants must complete Sections C, D, and E of this application.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 2 SECTION A Eligibility Statement  Designated Group Members Social Disadvantage 1. List all individuals claiming disadvantaged status:

Name of Individual Other Last U. S. Citizen Place of Birth Group Membership Sex Names Used Y/ N M/ F ________________ __________ __________ ___________ ________________ ____

________________ __________ __________ ___________ ________________ ____

________________ __________ __________ ___________ ________________ ____

________________ __________ __________ ___________ ________________ ____

2. Is at least 51% of each class of member interest unconditionally owned by one or more disadvantaged individuals? ___ Yes ___ No.

3. List all individuals claiming disadvantaged status.

Name of Individual Other Last U. S. Citizen Place of Group Sex Names Used Y/ N Birth Membership M/ F __________________________ ___________ ________ ___________ _______ ___ ____

__________________________ ___________ ________ ___________ __________ ____

__________________________ ___________ ________ ___________ __________ ____

3a. If you are a naturalized United States Citizen, please provide the following as Attachment A 1: ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

SECTION B Eligibility Statement  Non Designated Group Members Social Disadvantage 1. Is at least 51% of each class of member interest unconditionally owned by one or more disadvantaged individual? ___ Yes ___ No.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 3 2. List all individuals claiming disadvantaged status:

Name of Individual U. S. Citizen Race Sex Y/ N M/ F _______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

_______________________________ ________ ________ _____

2a. If you are a naturalized Citizen, please provide the following as Attachment B 1: ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

For this section, each individual claiming social disadvantage must provide a separate response for questions 3 through 5.

Social Disadvantage 3. I, ____________________________________ have personally suffered social disadvantage based on my identification as __________________________________. ( A claim of social disadvantage must include at least one objective feature that has contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, long term residence in an environment isolated from the mainstream of American society, or other similar causes not common to individuals who are not socially disadvantaged.)

4. Document how your ability to compete in the free enterprise system has been impaired by such things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or leases; restriction of your market to certain racial, ethnic or social groups; underemployment or unemployment, etc., as compared to others in the same or similar line of business who are not socially disadvantaged. Provide as Attachment B 2.

5. Attach a narrative describing how you personally experienced social disadvantage in American society. When writing your narrative, be as specific and detailed as possible. Where applicable, each statement of alleged discrimination should be supported by documented evidence such as affidavits, denials of loan applications, denials of employment opportunities ( including non selection for particular jobs, denials of promotions, or unequal work environment or treatment), and documents to support any formal action taken by you because of alleged discrimination. You must demonstrate how your identification, as described in the paragraph above, has negatively impacted your entry into or advancement in business. You must address disadvantage in education, employment, and business history, where applicable. Examples of discrimination include, but are not limited to: unequal access to colleges or professional schools; exclusion from professional or business associations; being denied educational honors or recognition; experiencing discriminatory social pressure which discouraged you from pursuing a professional or higher education or forced you into non professional or non business fields; discrimination in employment opportunities or pay and fringe benefits; unequal access to business credit or capital; and discrimination in the awarding, bidding process, or negotiating of government or private sector contracts. Provide as Attachment B 3.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 4 SECTION C ( All applicant firms must complete)

Economic Disadvantage 1. Is the net worth of each individual( s) claiming disadvantaged status less than $ 750,000, excluding your ownership interest in the applicant firm and equity in the individual( s) primary residence? ____ Yes ____ No.

2. For individuals claiming disadvantaged status, list your personal net worth, excluding the ownership interest in the applicant firm and the equity in the individual( s) primary residence.

Name Average 2 year Personal Total Income Net Worth Assets ________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

________________________________ ______________ __________ __________

3. Each individual listed in number 2 above, certifies that because of racial and/ or ethnic prejudice, and/ or cultural bias, his/ her ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business that are not socially disadvantaged.

SECTION D ( All applicant firms must complete)

Ownership 1. If more than one class membership interest, provide information for each class: Voting Non Total Voting a) Total number of interests authorized: _____ ______ _____ b) Total number of interests currently outstanding: _____ ______ _____

2. List all individuals, entities, and/ or trusts, which have a membership interest in the applicant firm.

Name Title Membership Percent Voting Non Voting Total ___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 5 3. Do disadvantaged individuals receive at least 51% of the annual distributions of dividends paid on the membership interest of an LLC applicant firm? ____ Yes ____ No ____ N/ A. If no or not applicable ( N/ A), please explain as Attachment D 1.

4. Will disadvantaged individuals receive 100% of the unencumbered value of each share of membership interest in the event that the interest is sold? ___ Yes ___ No. If no, please explain as Attachment D 2.

5. If the LLC dissolves, will disadvantaged individuals receive at least 51% of the retained earnings and 100% of the unencumbered value of each membership he or she owns? ___ Yes ___ No. If no, please explain as Attachment D 3.

6. Is ownership by any individual claiming disadvantaged status subject to conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements, or other similar arrangements, which may impact the unconditional ownership of such individuals? ___ Yes ___ No. If yes, explain as Attachment D 4.

7. Have there been any changes in ownership in the last year? ____ Yes ____ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment D 5.

8. For community property residents only. If you are a married disadvantaged owner, and your spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a majority interest in the business.

Name of Disadvantaged Owner State of Residence Percent Transferred __________________________________ _______ _____________

__________________________________ _______ _____________

__________________________________ _______ _____________

__________________________________ _______ _____________

9. Has any individual( s) listed in number 2 above transferred any assets within two years, in full or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes, provide the following information as Attachment D 6: the date of transfer; to whom the assets were transferred; amount paid for the assets; and the market value of the assets at the time of transfer. Individuals may exclude assets transferred to an immediate family member that are consistent with the customary recognition of special occasions, such as birthdays, graduations, anniversaries, and retirements. Individuals may also exclude any transfers to an immediate family if for educational, medical, or essential support purposes.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 6 SECTION E ( All applicant firms must complete)

Control 1. List the titles of all officers, management members, and key managers and the hours devoted, by such individual( s) to the management of the applicant firm.

Name Title ____________________________ _______________________________

_____________________________ _______________________________

_____________________________ _______________________________

_____________________________ _______________________________

2. Is the managing member or any disadvantaged full time manager engaged in or plan to engage in outside employment? ____ Yes ____ No. If yes, provide details as to the extent of outside employment or other business dealings to include daily hours of employment, location, and explanation as to how this outside employment does not conflict with the ability to manage and control the daily operations of the application concern. Provide as Attachment E 1.

3. Have any of the nondisadvantaged individuals involved in the management of the applicant firm, and/ or their immediate family members, had a prior business relationship with any individual claiming disadvantaged status? This includes such relationships as employer employee, supervisoremployee co workers, investor employee, etc. ____ Yes ____ No. If yes, identify the person( s) and the type of business relationship as Attachment E 2.

4. Does any nondisadvantaged individual receive compensation in any form, including dividends, as a director, officer, or employee that exceeds the compensation received by the disadvantaged Management Member? ____ Yes ____ No. If yes, provide the total compensation received by the disadvantaged management member, and the name( s) and the amount of the total compensation paid to the nondisadvantaged individuals( s). If any nondisadvantaged individual is higher compensated, provide a statement, which justifies the need for the nondisadvantaged individual( s) to receive a higher compensation. Provide as Attachment E 3.

5. Does the applicant firm operate in an industry, which requires bonding or professional licenses? ____ Yes ____ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm on Attachment E 4.

6. List the names of all individuals who have access to the firm's bank account.

Name Title ___________________________________ ___________________________________

___________________________________ ___________________________________

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 7 7. Does any individual( s), ( other than the individual( s) claiming disadvantaged status) or entities provide?

a) Financial support to the applicant firm ____ Yes ____ No b) Subcontracts, Joint Ventures or Teaming Arrangements ____ Yes ____ No c) Office space ( rent or leased) ____ Yes ____ No d) Equipment ( rent or leased) ____ Yes ____ No e) Employees ( other than from employment agencies) ____ Yes ____ No f) Business bank account ____ Yes ____ No If you answered yes to any of the above, please provide details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment E 5.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 8 Each person signing below:

1. Certifies that the information provided with regard to my social and economic disadvantaged status is true, accurate, and complete to the best of my knowledge and belief.

2. Certifies that the information provided with regard to my ownership and control status is true, accurate, and complete to the best of my knowledge and belief.

3. Certifies that the information provided with regard to my status as a United States citizen is true, accurate, and complete to the best of my knowledge and belief.

4. Certifies that the information provided with regard to my individual disadvantaged status is true, accurate, and complete to the best of my knowledge and belief.

5. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate and complete to the best of my knowledge and belief.

6. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state, and local agencies for determining violations of law.

7. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting and recordkeeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001, which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 9 http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1b) ( Limited Liability Company) 10 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program Native Hawaiian Organization Owned Concern Name of Parent Native Hawaiian Organization: _________________________________________

Address of Parent Native Hawaiian Organization: _______________________________________

Name of wholly owned subsidiary ( if applicable): _______________________________________

Address of wholly owned subsidiary: __________________________________________________

Name of applicant firm: ______________________________________________________________

Applicant concern is:  Corporation  Limited Liability Company  Partnership Name of President/ Managing Member/ Managing Partner: _______________________________

EIN: _________________________ E mail Address: _____________________________________

Business Address: _____________________________________________ County: _____________

City: _________________________________ State: _______________ Zip Code: _______________

Phone Number: ___________________________ Fax Number: _____________________________

Mailing Address ( if different than above): ________________________ County: _______________

City: _________________________________ State: _______________ Zip Code: _______________

What is the firm's ( 4 digit) primary standard industrial classification code? _________________

Is the firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide Pro Net Number________________________________

Is the firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide Pro Net number___________________

Is the firm certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s) __________________________________________________

Is the firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity ____________________________________________________________

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanation/ documentation: _____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Does the firm have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc? ___ Yes ___ No. If yes, provide the State( s) and ID number( s): __________________ __________________________________________________________________________________

Business Eligibility SECTION A Social Disadvantage 1. A Native Hawaiian Organization that meets the following criteria is considered socially disadvantaged:

Native Hawaiian Organization means any community service organization serving Native Hawaiians in the State of Hawaii, which is a not for profit organization, chartered by the State of Hawaii. A Native Hawaiian Organization is controlled by Native Hawaiians whose business activities will principally benefit such Native Hawaiians.

Provide documentation that the applicant entity meets these criteria as Attachment A 1.

SECTION B Economic Disadvantage 1. Is the net worth of all individual( s) claiming disadvantaged status less than $ 750,000, excluding ownership interest in the applicant firm and equity in the individual( s) primary residence? ____ Yes ____ No.

2. For individual( s) claiming disadvantaged status, list your personal net worth, excluding the ownership interest in the applicant firm and the equity in the individual( s) primary residence.

Name Average 2 year Personal Total U. S. Income Net Worth Assets Citizen ( Y/ N)

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

____________________________ ______________ __________ _______ ___________

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 2 3. Each individual listed in number 2 above certifies that, because of racial and/ or ethnic prejudice, and/ or cultural bias, his/ her ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business that are not socially disadvantaged.

4. Personal Financial Statement  All individuals claiming disadvantaged status and his/ her spouse, please provide documentation verifying your assets and liabilities ( split your assets and liabilities, if married) as Attachment B 1.

5. All individuals claiming disadvantaged status or individuals owning more than 10% of the concern please provide the following documentation as Attachment B 2:

a) Signed copies of individual Federal income tax returns filed for the past two years, including all W 2 forms and all schedules and attachments. b) Signed and dated IRS Form 4506 ( Request for Copy or Transcript of Tax Form)

SECTION C Ownership 1. Do Native Hawaiians own a majority of both the total equity of the Native Hawaiian Organization and the total voting powers to elect directors of the Native Hawaiian Organization? ___ Yes ___ No. If yes, provide verification of the percentage of Native Hawaiian ownership as attachment C 1.

2. Is the applicant concern at least 51 percent owned by a Native Hawaiian Organization? ____ Yes ____ No. If yes, please provide evidence of ownership as Attachment C 2.

Corporations Only:

3. If more than one class of stock, provide information for each class: Voting Non Total Voting a) Total number of shares authorized: _____ ______ _____ b) Total number of shares currently outstanding: _____ ______ _____

4. Please provide the following documentation as Attachment C 3: a) Copies of all governing documents, such as the concern's constitution or business charter. b) Copies of all minutes of shareholders meeting electing board of directors and minutes of last shareholders meeting. c) Copies of all stock certificates ( front and back) and stock register. d) Copy of the current Certificate of Good Standing from state where concern is incorporated. If concern conducts business in a state other than where it was incorporated, a copy of the filing as a Foreign Corporation and a current Certificate of Good Standing from that state are required as well.

Limited Liability Companies Only:

5. If more than one class membership interest, provide information for each class: Voting Non Total Voting a) Total number of memberships authorized: _____ ______ _____ b) Total number of memberships currently outstanding: _____ ______ _____

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 3 6. Please provide the following documentation as attachment C 4: a) Copy of Operating Agreement b) Copy of Articles of Organization as filed with the state Partnerships Only:

7. Provide the name, title, and percentage of ownership for each partner of the firm. Does the partnership agreement reflect the ownership of each partner? ___ Yes ___ No.

Name Title Ownership %

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

___________________________ ____________________ ____________________

8. Please provide a copy of the concern's Partnership Agreement as Attachment C 5.

Questions 9 through 13 are for Corporations & LLCs ONLY:

9. List all entities, individuals, and/ or trusts which have an ownership interest in the applicant firm.

Name Title Ownership % Voting NonVoting Total ___________________________ ____________________ ______ _________ _____

___________________________ ____________________ ______ __________ _____

___________________________ ____________________ ______ __________ ______

___________________________ ____________________ ______ __________ ______

10. Does the parent Native Hawaiian Organization or its wholly owned subsidiary receive at least 51% of the annual distributions of dividends paid on the stock of a corporate applicant firm? ___ Yes ___ No. If no, please explain as Attachment C 6.

11. Will the parent Native Hawaiian Organization or its wholly owned subsidiary receive 100% of the unencumbered value of each share of stock owned in the event that the stock is sold? ___ Yes ___ No. If no, please explain as Attachment C 7.

12. If the corporation dissolves, will the parent Native Hawaiian Organization or its wholly owned subsidiary receive at least 51% of the retained earnings and 100% of the unencumbered value of each share of stock owned? ___ Yes ___ No. If no, please explain as Attachment C 8.

13. Is ownership by the parent Native Hawaiian Organization or its wholly owned subsidiary subject to conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar arrangements which may impact the unconditional ownership of the Native Hawaiian Organization? ___ Yes ___ No. If yes, explain as Attachment C 9.

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 4 Corporations, LLCs & Partnerships:

14. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment C 10.

For All Concerns:

15. Please provide copies of buy/ sell agreements, conditions precedent, conditions subsequent, executory agreements, voting trusts, shareholder agreements or other similar arrangements, which may impact the unconditional ownership of the disadvantaged individuals as Attachment C 11.

SECTION D Control and Management 1. List all individuals who manage or conduct daily business operations of the applicant concern.

Name/ Title Date ___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

___________________________________________________ _____________

2. Are any of the individuals listed in question 1 engaged in or plan to engage in outside employment? ___ Yes ___ No.

3. If members of the management team, business committee members, officers, and directors are currently employed outside the applicant concern, provide information on this employment and evidence that the activity does not conflict with the day to day management of the applicant concern. Please indicate the number of hours per week and the normal working hours of this outside employment as Attachment D 1.

4. Please provide resumes of the education, technical training and business and employment experience, including employer's names, dates of employment, for general manager, officers, and key employees ( Please account for any missing gaps in employment) as Attachment D 2.

5. List the total compensation from the applicant firm of all owners and/ or key managers of the firm. ( If necessary, provide additional information as Attachment D 3).

Name/ Title Compensation from applicant firm ( Include salaries, bonuses, etc.)

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 5 6. Does the applicant firm operate in an industry which requires bonding or professional licenses? ___ Yes ___ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm on Attachment D 4.

7. List the names of all individuals who have access to the firm's bank account.

Name Title ___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

___________________________________ __________________________________

8. Do any individual( s), or entities provide:

a) Financial support to the applicant firm? ___ Yes ___ No b) Subcontracts, Joint Ventures or Teaming Arrangements? ___ Yes ___ No c) Office space ( rent or leased). ___ Yes ___ No d) Equipment ( rent or leased). ___ Yes ___ No e) Employees ( other than from employment agencies). ___ Yes ___ No If the answer is yes to any of the above, please provide specific details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment D 5.

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 6 Each person signing below:

1. Certifies that the information provided with regard to the applicant firm's social and economic disadvantaged status is true, accurate, and complete to the best of his/ her knowledge and belief.

2. Certifies that the information provided with regard to the applicant firm's ownership and control status is true, accurate, and complete to the best of his/ her knowledge and belief.

3. Certifies that the information provided with regard to his/ her individual disadvantaged status is true, accurate, and complete to the best of his/ her knowledge and belief.

4. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate, and complete to the best of his/ her knowledge and belief.

5. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, State, and local agencies to determine violations of law.

6. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

All officers, directors, partners, members of the governing board and owners of more than 10% must sign below.

Name SSN Date ________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

________________________ _______________________ ______________________

The public reporting and record keeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose, or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001, which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 7 to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( EPA Form 6100 1h) ( Native Hawaiian Organization Owned Concern) 8 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program For Sole Proprietorships Business Profile:

Name of applicant firm:_______________________________________________

Name of Sole Proprietor and Title:______________________________________________

SSN of Sole Proprietor:_________ E mail Address:________

Business Address:____________________________________________ County:_____________________

City:_________________________________ State:_______________ Zip Code:______________________

Phone Number:___________________________ Fax Number:_____________________________________

Mailing Address ( if different than above):_________________________ County:______________________

City:_________________________________ State:_______________ Zip Code:______________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? ____________

Are you claiming disabled status? ____ Yes ____ No ( i. e., a United States citizen who has permanent or temporary physical or mental impairment that substantially limits one or more of your major life activities.) If yes, please submit documentation substantiating such disability.

Is your firm at least 51% owned by a Disabled American? ____ Yes ____ No.

Are you certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide PRO Net number ______________________________________________

Are you certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide PRO Net number ____________________________________

Are you certified as a DBE by a Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s) _________________________________________________

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) Are you certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and a contact point at the certifying entity ____________________________________________________

Have you ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide a copy of the prior determination of attempts to obtain certification: _________________________________________________________________________________________ Do you have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc.? ___ Yes ___ No. If yes, provide State( s) and ID number( s).

In accordance with 13 CFR § 124.103, designated group members are presumed to be socially disadvantaged. Designated group members are individuals who hold themselves out to be and are identified by others as Black Americans, Native Americans ( American Indians, Eskimos, Aleuts, or Native Hawaiians), Hispanic Americans, Subcontinent Asian Americans, Asian Pacific Americans, and any other groups designated by the Small Business Administration ( SBA). If an individual is claiming to be a member of a designated group, complete Section A of this application. If an individual is not claiming to be a member of a designated group, complete Section B of this application. All applicants must complete Sections C, D, and E of this application.

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 2 SECTION A Eligibility Statement  Designated Group Members Social Disadvantage 1. As the proprietor claiming disadvantaged status, complete the following:

Name of Individual Other Last Citizen Place of Group Sex Names Used Y/ N Birth Membership _________________ ___________ ________ ___________ _______ _____

If you are not a U. S. citizen, stop here. You are not eligible to participate as a DBE under EPA's DBE Certification Program.

1a. If you are a naturalized United States Citizen, please provide the following as Attachment A 1: ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

SECTION B Eligibility Statement  Non Designated Group Members 1. As the proprietor claiming disadvantaged status, complete the following:

Name of Individual U. S. Citizen Race Sex Y/ N M/ F _______________________________ ________ 1a. If you are a naturalized Citizen, please provide the following as Attachment B 1: ( a) naturalization number; ( b) date of citizenship; and ( c) county, state and court.

For this section, any individual claiming social disadvantage must provide a separate response for questions 3 and 4.

Social Disadvantage 2. I, ____________________________________ have personally suffered social disadvantage based on my identification as __________________________________. ( A claim of social disadvantage must include at least one objective feature that has contributed to social disadvantage, such as race, ethnic origin, gender, physical handicap, long term residence in an environment isolated from the mainstream of American society, or other similar causes not common to individuals who are not socially disadvantaged.)

3. Document how your ability to compete in the free enterprise system has been impaired by such things as inability to obtain adequate bonding, credit or financing; inability to obtain licenses or leases; restriction of your market to certain racial, ethnic or social groups; underemployment or unemployment, etc., as compared to others in the same or similar line of business who are not socially disadvantaged. Provide as Attachment B 2.

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 3 4. Attach a narrative describing how you personally experienced social disadvantage in American society. When writing your narrative, be as specific and detailed as possible. Where applicable, each statement of alleged discrimination should be supported by documented evidence such as affidavits, denials of loan applications, denials of employment opportunities ( including non selection for particular jobs, denials of promotions, or unequal work environment or treatment), and documents to support any formal action taken by you because of alleged discrimination. You must demonstrate how your identification, as described in the paragraph above, has negatively impacted your entry into or advancement in business. You must address disadvantage in education, employment, and business history, where applicable. Examples of discrimination include, but are not limited to: unequal access to colleges or professional schools; exclusion from professional or business associations; being denied educational honors or recognition; experiencing discriminatory social pressure which discouraged you from pursuing a professional or higher education or forced you into non professional or non business fields; discrimination in employment opportunities or pay and fringe benefits; unequal access to business credit or capital; and discrimination in the awarding, bidding process, or negotiating of government or private sector contracts. Provide as Attachment B 3.

SECTION C ( All applicant firms must complete)

Economic Disadvantage 1. Is your net worth less than $ 750,000, excluding your ownership interest in the applicant firm and your equity in your primary residence? ____ Yes ____ No.

2. As the individual claiming disadvantaged status, list your personal net worth, excluding the ownership interest in the applicant firm and the equity in the primary residence.

Name Average 2 year Personal Total Income Net Worth Assets ________________________________ ______________ __________ __________

3. I, ___________________________, certify that because of racial and/ or ethnic prejudice, and/ or cultural bias, my ability to compete in the free enterprise system has been impaired due to diminished capital and credit opportunities as compared to others in the same or similar line of business that are not socially disadvantaged.

SECTION D ( All applicant firms must complete)

Ownership 1. Have you, the individual claiming disadvantaged status, transferred any assets within two years, in full or in part, to a spouse or any other person or entity, including a trust? ___ Yes ___ No. If yes, provide the following information as Attachment D 1: the date of transfer; to whom the assets were transferred; amount paid for the assets; and the market value of the assets at the time of transfer. Individuals may exclude assets transferred to an immediate family member that are EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 4 consistent with the customary recognition of special occasions, such as birthdays, graduations, anniversaries and retirements. Individuals may also exclude any transfers to an immediate family member if for educational, medical or essential support purposes.

For community property residents only. If you are a married disadvantaged owner, and your spouse is not disadvantaged, please complete the chart below, and provide evidence that you have a majority interest in the business.

Name of Disadvantaged Owner State Percent Transferred ____________________________ _______ __________________

2. Have there been any changes in ownership in the last year? ___ Yes ___ No. If yes, did ownership affect the disadvantaged status of your firm? Please explain as Attachment D 2.

SECTION E ( All applicant firms must complete)

Control 1. Does any individual other than the Sole Proprietor manage or conduct daily business operations of the applicant concern? If yes, provide name, title and dates.

Name/ Title Date ___________________________________ ____________________________

___________________________________ ____________________________

___________________________________ ____________________________

2. Are you engaged in or plan to engage in outside employment? ___ Yes ___ No. If yes, explain as Attachment E 1.

3. If the answer to question 2 is yes, have any of the nondisadvantaged individuals involved in the management of the applicant firm, or their immediate family members, had a prior business relationship with you? This includes such relationships as employer employee, supervisoremployee co workers, investor employee, etc. ___ Yes ___ No ___ N/ A. If yes, identify the person( s) and the type of business relationship as Attachment E 2.

4. List the total compensation from the applicant firm of all owners and/ or key managers of the firm. ( If necessary, provide additional information as Attachment E 3).

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 5 Name/ Title Compensation from applicant firm ( Include salaries, bonuses, etc.)

_____________________________________ __________________________________

_____________________________________ __________________________________

_____________________________________ __________________________________

_____________________________________ __________________________________

_____________________________________ __________________________________

5. Does the applicant firm operate in an industry which requires bonding or professional licenses? ___ Yes ___ No. If yes, identify the qualifying individual( s) for the critical licenses, general indemnity agreement, permits, certifications, and bonding required to operate the applicant firm on Attachment E 4.

6. List the names of all individuals who have access to the firm's bank account.

Name Title ____________________________________ _________________________________

____________________________________ _________________________________

____________________________________ _________________________________

7. Does any individual( s), ( other than the Sole Proprietor) or entities provide:

a) Financial support to the applicant firm? ___ Yes ___ No b) Subcontracts, Joint Ventures or Teaming Arrangements? ___ Yes ___ No c) Office space ( rent or leased). ___ Yes ___ No d) Equipment ( rent or leased). ___ Yes ___ No e) Employees ( other than from employment agencies). ___ Yes ___ No If you answered yes to any of the above, please provide specific details ( i. e., names, titles, copies of agreements, leases, etc.) of such arrangements as Attachment E 5.

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 6 Each person signing below: 1. Certifies that the information provided with regard to my social and economic disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

2. Certifies that the information provided with regard to my ownership and control status is true, accurate and complete to the best of my knowledge and belief.

3. Certifies that the information provided with regard to my status as a United States citizen is true, accurate and complete to the best of my knowledge and belief.

4. Certifies that the information provided with regard to my individual disadvantaged status is true, accurate and complete to the best of my knowledge and belief.

5. Certifies that the information provided, including that shown on documents accompanying this application, is true, accurate and complete to the best of my knowledge and belief.

6. Acknowledges that EPA, at its discretion, may give the information submitted to Federal, state and local agencies for determining violations of law.

7. Acknowledges that EPA's approval of an application does not affect the Government's right to pursue criminal prosecution for incorrect or incomplete information given on the application form, even if correct information has been included in other materials submitted to EPA.

Name SSN Date ________________________ ___________________ _______________________

________________________ ___________________ _______________________

________________________ ___________________ _______________________

________________________ ___________________ _______________________

The public reporting and record keeping burden for this collection of information is estimated to average three ( 3) hours. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, disclose or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

To comment on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including the use of automated collection techniques, EPA has established a public docket for this ICR under Docket ID No. OA 2002 0001, which is available for public viewing at the OEI Docket in the EPA Docket Center ( EPA/ DC), EPA West, Room EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 7 B102, 1301 Constitution Ave., NW, Washington, DC. The EPA Docket Center Public Reading Room is open from 8: 30 a. m. to 4: 30 p. m., Monday through Friday, excluding legal holidays. The telephone number for the Reading Room is ( 202) 566 1744, and the telephone number for the OEI Docket is ( 202) 566 1752). An electronic version of the public docket is available through EPA Dockets ( EDOCKET) at http:// www. epa. gov/ edocket. Use EDOCKET to submit or view public comments, access the index listing of the contents of the public docket, and to access those documents in the public docket that are available electronically. Once in the system, select " search," then key in the docket ID number identified above. Also, you can send comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, 725 17th Street, NW, Washington, DC 20503, Attention: Desk Office for EPA. Please include the EPA Docket ID No. ( OA 2002 0001) in any correspondence.

EPA DBE Certification Application ( Form 6100 1a) ( Sole Proprietorship) 8 OMB Control No: ______ Approved: ______ Approval Expires: ______ Environmental Protection Agency EPA DBE Certification Application For a Minority Business Enterprise ( MBE)/ Women owned Business Enterprise ( WBE) Under EPA's Disadvantaged Business Enterprise ( DBE) Program Tribally Owned Businesses Name of Indian tribe:_______________________________________________________________

Address of tribe:___________________________________________________________________

Name of wholly owned Subsidiary ( if applicable):____________________________________________________________

Address of wholly owned Subsidiary:_______________________________________________________________________

Name of applicant firm:____________________________________________________________

Applicant concern is: Corporation Limited Liability Company Partnership Name of President/ Managing Member/ Managing Partner:_______________________________

EIN:_________________________ E mail Address:______________________________________

Business Address:______________________________________________ County:_____________

City:_________________________________ State:_______________ Zip Code:________________

Phone Number:___________________________ Fax Number:______________________________

Mailing Address ( if different than above):________________________ County:________________

City:_________________________________ State:_______________ Zip Code:________________

What is the firm's 4 digit primary North American Industrial Classification ( NAIC) code? __________________________________________________________________________________

Is your firm certified by the Small Business Administration under its 8( a) Business Development Program? ___ Yes ___ No. If yes, provide Pro Net number:________________________________

Is your firm certified by the Small Business Administration under its Small Disadvantaged Business ( SDB) Program? ___ Yes ___ No. If yes, provide Pro Net number: ____________________

Is your firm certified as a DBE by a U. S. Department of Transportation recipient? ___ Yes ___ No. If yes, provide State( s) and ID number( s): _________________________________________

EPA DBE Certification Application ( EPA Form 6100 1f) ( Tribally Owned Businesses) Is your firm certified by a State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide ID number and the certifying entity: ____________________________________________________________________________

Has your firm ever been denied certification by a Federal agency, State government, local government, Indian tribal government, or independent private organization? ___ Yes ___ No. If yes, provide explanation/ documentation:____________________________________________________________ _____________________________________________________________________________________

Do you have any other certification as a disadvantaged business entity, i. e., MBE, DBE, WBE, etc? ___ Yes ___ No. If yes, provide State( s) and ID number( s): ________________________________

Is the applicant firm a for profit business? ___ Yes ___ No.

Do the tribe's articles of incorporation/ articles of organization/ partnership agreement contain express sovereign immunity waiver language or a " sue and be sued" clause which designates United States Federal Courts to be a competent jurisdiction for all matters relating to EPA's DBE Program? ___ Yes ___ No. If yes, provide a complete copy of the documentation as attachment D 3.

EPA DBE Certification Application ( EPA Form 6100 1f) ( Tribally Owned Businesses) 2 Business Eligibility SECTION A Social Disadvantage 1. An Indian tribe that meets the following criteria is considered socially disadvantaged:

Indian tribe means any Indian tribe, band, nation, or other organized group or community of Indians which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians, or is recognized as such by the State in which the tribe, band, nation, group or community resides.

Provide documentation that the applicant entity meets these criteria as Attachment A 1.

2. Provide copies of the tribe's articles of incorporation and bylaws as filed with the organizing or chartering authority, or similar documents needed to establish and govern a non corporate legal entity as Attachment A 2.

SECTION B Economic Disadvantage 1. Has the tribe previously established economic disadvantage to qualify as DBE? ___ Yes ___ No. If yes, provide documentation to verify disadvantaged status as Attachment B 1.

If no, respond to the following questions as Attachment B 2:

a) What is the number of tribal members on tribal rolls as of the date of application? b) What is tribe's present unemployment rate? c) What is the per capita income of tribal members excluding judgment awards? d) What is the percentage of the local Indian population below the poverty level? e) What is the total tribal income for the applicant tribe? f) What are the tribe's assets as disclosed in a tribal financial statement? g) Provide a list of all wholly or partially owned tribal enterprises or affiliates and the primary industry classification of each. The listing should include the members of the tribe who manage or control such enterprises by serving as officers or directors.

2. The Indian Tribe must also submit the following documentation to substantiate a claim of economic disadvantage:

a) A copy of all governing documents such as the tribe's constitution or business charter. b) Evidence of its recognition as a tribe eligible for the special programs and services provided by the United States or by its state of residence.

EPA DBE Certification Application ( EPA Form 6100 1f) ( Tribally Owned Businesses) 3 SECTION C Ownership Corporations Only:

1. Does the tribe firm own at least 51% of the voting stock? ____ Yes ____ No. Please provide documentation as attachment C 1.

2. Does the tribe own at least 51% of the aggregate if all classes of stock? ___ Yes ___ No. Please provide documentation as attachment C 2.

3. If more than one class of stock, provide information for each class:

Voting Non Total Voting a) Total number of shares authorized: _____ ______ ______ b) Total number of shares currently outstanding: _____ ______ ______

Non Corporate Entities Only:

4. Does the tribe own at least 51% interest in the firm? ___ Yes ___ No. Please provide documentation as attachment C 3.

5. If more than one class membership interest, provide information for each class:

Voting Non Total Voting a) Total number of memberships authorized: _____ ______ _____ b) Total number of memberships currently outstanding: _____ ______ _____

For Corporate and Non Corporate Entities:

6. Does the tribe currently own 51% or more of another firm under the same primary NAIC code? ___ Yes ___ No.

7. Within the last two years has the tribe owned 51% or more of another firm under the same primary NAIC code as the applicant? ___ Yes ___ No.

SECTION D Control and Management 1. Are the management and daily business operations of the tribe controlled by the tribe through one or more disadvantaged individual members who possess sufficient management experience of an extent and complexity to run the concern? ___ Yes ___ No. If yes, provide documentation to verify tribal membership and management competency as Attachment D 1.

EPA DBE Certification Application ( EPA Form 6100 1f) ( Tribally Owned Businesses) 4 2. Is the management of the tribe controlled by committees, teams, Boards of Directors, or one or more members of an economically disadvantaged tribe? ___ Yes ___ No. Please provide documentation as attachment D 2.

Management may be provided by non tribal members if it is determined that such management is required to assist the concern's development, provided that the tribe will retain control of all management decisions common to Boards of Directors, including strategic planning, budget approval and the employment and compensation of officers. However, a written management development plan must exist which shows how disadvantaged tribal members will develop managerial skills sufficient to manage the concern or similar tribally owned concerns in the future.

3. Are members of the management team, business committee members, officers, and directors engaged in any outside employment or other business interests which conflict with the management of the tribe? ___ Yes ___ No.

4. List the titles of all officers, directors, management members, partners and key managers and the hours devoted, by such individual( s) to the management of the tribe.

Name Title Hours ____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

____________________________ _______________________________ __________

5. List the names of all individuals who have access to the tribe's bank account.

Name Title ___________________________ __________________________

__________________________ __________________________

__________________________ __________________________

__________________________ __________________________

EPA DBE Certification Application ( EPA Form 6100 1f) ( Tribally Owned Businesses) 5 Each person signing below: