[City of Grand Forks] PW Lead Service Form due 7/1/25

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Signature HereSigner2 Will Sign Here

(date to be determined)

IF EMAIL ADDRESS OF CONTRACTOR IS UNKNOWN, IN NEXT POP UP WINDOW EMAIL TO DAHANSON@GRANDFORKSGOV.COM

04/27/2026Click to Sign

*By signing this you are agreeing to pay the contractor any amount of the replacement cost not covered by federal or city funding. Any warranty work is the responsibility of the contractor under the agreement you have with them.

**Application must be submitted with a quote from an approved Contractor. Please email quote to Dahanson@grandforksgov.com.
***If the estimated cost of replacement exceeds $15,000 three quotes from different approved contractors must be submitted.

I hereby certify that the information provided on and with this application is true and accurate to the best of my knowledge. I further certify to the Use of American Iron and Steel, compliance with BABA and that the specified Davis Bacon wage scale will be used as mandated in the U.S. Environmental Protection Agency's State Revolving Fund programs, to following all applicable state regulations, and applicable local ordinances and regulations, and that all lead service line replacements will result in the complete removal of the lead service line and associated materials from the Utility's water main to the water meter within the structure. I also certify that a good faith effort was made to solicit subcontractors (if used) meeting the DBE requirements.

Estimated Linear Feet of Replacement: ___________

Will Water Meter be Moved? YES ___ NO ___

Will Electrical System Ground be Altered? YES ___ NO ___

Will Concrete be Removed? YES ___ NO ___

Estimated Start Date: ______________________

A plumber is required to move the water meter and Electrician is required to install new system ground. Quotes for both must be submitted to be eligible for reimbursement.

04/27/2026

If no, work may not proceed until the contractor completes the qualifications set forth by the NDDEQ

Signature HereDan A Hanson Will Sign Here

04/27/2026

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Dan A Hanson