WATER

CWSRF Technical Assistance Request

Entity / Organization

LDEQ Agency Interest Number

Under an Enforcement Action / Compliance Order?

Yes

No

Not Yet, but will be soon

(Select Status as of the date of this Request)

Contact Name

(First)

(Last)

Email Address

Phone Number

(Provide 10-digit phone number)

Type of Technical Assistance Request

Managerial

Technical / Operational

Financial / Funding

(Select All that Apply)

Timeframe for Technical Assistance Needed

(Select the most appropriate timeframe being requested)