The URL can be used to link to this page

Home My WebLink AboutUnity Point Health/Allen Hospital - LOA - EAP-5/23/2016UnityPoint Health MI Allen Hospital LETTER OF AGREEMENT ALLEN HOSPITAL agrees to provide the following services to employees, spouses and family dependents of CITY OF WATERLOO. 1) Provide prompt access to the employees for the Employee Assistance Program Services. 2) Provide assessment, short-term counseling and or referral to appropriate community service providers, being sensitive to the employee's financial status and health care benefits. Benefits include 6 EAP sessions per employee, domestic partner and dependents per calendar year, with limit of 3 issues/person/year. 3) Secure a Release of Information from the employee allowing ALLEN HOSPITAL to confirm the employee's involvement with the referral provider. 4) Maintain accurate case management records and comply with all State and Federal statutes regarding confidentiality. 5) Provide supervisory/management staff of CITY OF WATERLOO training specific to utilization of the Employee Assistance Program, within 45 days of the program initiation. 6) Provide information to all employees of CITY OF WATERLOO regarding utilization of the Employee Assistance Program. 7) Provide CITY OF WATERLOO with written yearly reports outlining utilization. 8) As requested, provide consultation to supervisory/management staff. CITY OF WATERLOO agrees to: 1) Pay ALLEN HOSPITAL a fee per capita of $25.00 per each employee per year. Quarterly billing will be for services available in the upcoming quarter. Terms are net 30 days. 2) Supply ALLEN HOSPITAL with information on the insurance benefits of the contracting company: 3) Provide access to all employees to the Employee Assistance Program of ALLEN HOSPITAL and written information as to utilization. pi UnityPoint Health i Allen Hospital LETTER OF AGREEMENT -continued CITY OF WATERLOO PAGE TWO Please return this copy t5: City Clerk & Finance Dept. 715 Mulberry St. Waterloo, IA 50703 4) Provide ALLEN HOSPITAL with a copy of the company substance abuse policy. This Agreement is made as of July 1, 2016 and shall continue in effect for one (1) year. In the event the Agreement between ALLEN HOSPITAL Employee Assistance Program and CITY OF WATERLOO is extended, the Agreement shall automatically be extended for a period consistent with that period. The existing capitated fee will remain in effect until 1/01/2017, at which time ALLEN HOSPITAL reserves the right to institute a rate increase. Either party may discontinue this Agreement upon sixty (60) days prior written notice. Termination between ALLEN HOSPITAL Employee Assistance Program and CITY OF WATERLOO shall cause this agreement to automatically terminate. BY: BY: .2---17(1-.(44 - PAMELA K. DELAGARDELLE QUENTIN HART PRESIDENT & CEO MAYOR ALLEN HOSPITAL CITY OF WATERLOO DATE: DATE: 45 /el BY: BY: DATE: AMANDA L. SCHARA, LMHC, CADC EAP MANAGER ALLEN HOSPITAL DATE: SUZY S t. HARES CITY CL RK/HR DIRECTOR CITY OF WATERLOO FACILITY LOCATION OR LOCATION OF CONSTRUCTION SITE Give the location by'/4 section, section, township, range, (e.a.. NW. 7, T78N. R3W 1/4 SECTION SECTION TOWNSHIP RANGE. NE'/4 26 89 N 13 W OWNER INFORMATION Enter the name and full address of the owner of the facili . MAIL TO: STORM WATER COORDINATOR IOWA DEPARTMENT OF NATURAL RESOURCES 502 E. 9'n STREET DES MOINES, IA 50319-0034 NAME: City of Waterloo, Iowa CITY: Waterloo STATE: Iowa ADDRESS: City Hall, 715 Mulberry Street ZIP CODE: 50703 TELEPHONE: 319 291-4301 OUTFALL INFORMATION Discharge start date, i.e., when did/will the site begin operation or 10/1/92, whichever is later: June 13s` , 2016 Is any storm water monitoring information available describing the concentration of pollutants in storm water discharges? ❑ Yes ❑x No NOTE: Do not attach any storm water monitoring information with the application. Receiving water(s) to the first uniquely named waterway in Iowa, (e.g., road ditch to unnamed tributary to Mud Creek to South Skunk River): Urban roadway and building drainage to an existing storm sewer system ultimately to the Cedar River Compliance With The Following Conditions: Has the Storm Water Pollution Prevention Plan been developed prior to the submittal of this Notice of Intent and does the plan meet the requirements of the applicable General Permit? (do not submit the SWPPP with the application) Will the Storm Water Pollution Prevention Plan comply with approved State (Section 161A.64, Code of Iowa) or local sediment and erosion plans? (for General Permit 2 only) Have two public notices been published for at least one day, one each in the two newspapers with the largest circulation in the area where the discharge is located, and are the proofs of notice attached? (new applications only) Yes No X X X GENERAL PERMIT NO. 2 AND GENERAL PERMIT NO. 3 APPLICANTS COMPLETE THIS SECTION. Description of Project (describe in one sentence what is being constructed): Reconstruction and improvements to portions of existing W. 2"d , Cedar and W. 3rd Streets. For General Permit No. 3 - Is this facility to be moved this year? Number of Acres of Disturbed Soil: L. ❑ Yes ❑ No (Construction Activities Only) Estimated Timetable For Activities / Projects, i.e., approximately when did/will the project begin and end: Start: June 13`h, 2016 End: December 31s, 2016 CERTIFICATION — ALL APPLICATIONS MUST BE SIGNED Only the following individuals may sign the certification: owner of site, principal executive officer of at least the level of vice- president of the company owning the site, a general partner of the company owning the site, principal executive officer or ranking elected official of the public entity owning the site, any of the above of the general contracting company for construction sites. I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed to assure that qualified people properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, this information is to the best of my knowledge and belief, true, accurate, and complete. I further certify that the terms and conditions of the general permit will be met. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. NAME: (print or type) Quentin M. Hart TITLE: Mayor, City of Waterloo SIGNATURE: Gam, — A DATE: IOWA DEPARTMENT OF NATURAL RESOURCES ENVIRONMENTAL PROTECTION DIVISION NOTICE OF INTENT FOR NPDES COVERAGE UNDER GENERAL PERMIT No. 1 FOR "STORM WATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY" or No. 2 FOR "STORM WATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY FOR CONSTRUCTION ACTIVITIES" or No. 3 FOR "STORM WATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY FOR ASPHALT PLANTS, CONCRETE BATCH PLANTS, ROCK CRUSHING PLANTS, AND CONSTRUCTION SAND AND GRAVEL FACILITIES." PERMIT INFORMATION Has this storm water discharge been previously permitted? ❑ Yes i1 No If yes, please list authorization number Under what General Permit are you applying for coverage? General Permit No. 1 0 General Permit No. 2 ❑x General Permit No. 3 0 IDNR CASHIER'S USE ONLY 0253-542-SW08-0581 PERMIT FEE OPTIONS For coverage under the NPDES General Permit the following fees apply: ❑ Annual Permit Fee $175 (per year) Maximum coverage is one year. ❑x 3 -year Permit Fee $350 Maximum coverage is three years. ❑ 4 -year Permit Fee $525 Maximum coverage is four years. ❑ 5 -year Permit Fee $700 Maximum coverage is five years. Checks should be made payable to: Iowa Department of Natural Resources. FACILITY OR PROJECT INFORMATION Enter the name and full address/location (not mailing address) of the facility or project for which permit coverage is requested. NAME: F.Y. 2016 W.2", Cedar and W.3`d Streets Improvements STREET ADDRESS OF SITE: 325 Commercial St., Waterloo, IA CITY: Waterloo COUNTY: Black Hawk County STATE: Iowa ZIP CODE: 50701 CONTACT INFORMATION Give name, mailing address and telephone number of a contact person (Attach additional information on separate pages as needed). This will be the address to which all correspondence will be sent and to which all questions regarding your application and compliance with the permit will be directed. NAME- Phil Schuppert ADDRESS: 715 Mulberry Street CITY: Waterloo STATE: Iowa ZIP CODE: 50703 TELEPHONE (319 ) 291-4312 Check the appropriate box to indicate the legal status of the operator of the facility. 0 Federal 0 State 0 Public 0 Private 0 Other (specify) SIC CODE (General Permit No. 1 & 3 Applicants Only) SIC code refers to Standard Industrial Classification code number used to classify establishments by type of economic activity. Be sure to complete both sides of this form. 542-1415 (Rev. 7/08)