YOLO-SOLANO AIR QUALITY MANAGEMENT DISTRICT AGRICULTURAL EQUIPMENT AND PUBLIC FLEET PROGRAM

Transcription

1 YOLO-SOLANO AIR QUALITY MANAGEMENT DISTRICT AGRICULTURAL EQUIPMENT AND PUBLIC FLEET PROGRAM Application Form Instructions: One application form is required for each vehicle/piece of equipment. Read entire application package including attached draft agreement. Fill in all applicable sections. Type or print legibly. Submit this application form to: Yolo-Solano AQMD, 1947 Galileo Court, Suite 103; Davis, CA Date Received (For District use only) Applicant Information Applicant Mailing Contact Person City State Title Zip Code County Phone Number Fax Number Physical Fill in physical address below if different from mailing address City State Cell Number Zip Code County Authorized Representative who will sign the Incentive Agreement * Name: Title: * Individuals or companies that operate the existing equipment or will operate the replacement equipment under a lease agreement with the equipment owner are prohibited from applying for incentive funding. Contact person who filled out this application (if different from above) ** Name Company City State Phone Fax Zip Code Please attach copy of Vehicle/Equipment Title and DMV Registration to Application. Signature: ** If compensated for completing the application on the owner s/company s behalf, then attach details on the source of payment and the amount paid. Payment Request Options (Initial only one option): Date: OPTION 1 -- I request that payment be sent to the applicant above. OPTION 2 -- I request that a two-party check be made for this application co-naming the identified vendor providing services and/or technology (see page 4 of application) and that the payment be sent to applicant above. OPTION 3 -- I request that a two-party check be made for this application and I authorize that the two-party payment be sent to the identified vendor providing services and/or technology (see page 4 of application). Yolo-Solano Air Quality Management District Application Page 1 of 5 08/2014

2 Please initial each section (See Program Information Packet for additional details and requirements): The purchase of this low-emission technology is NOT required by any local, state, and/or federal rule or regulation. I have not and will not apply for additional grant funds from other government entities for this project. The vehicle/engine will be used in the Sacramento Federal Ozone Non-Attainment Area (with the emission reduction system operating, if applicable) for at least the projected usage shown in this application. I understand that the Incentive Agreement language cannot be modified. I have reviewed and accepted the Incentive Draft Agreement language. I understand that payments made under this Incentive Program may be subject to taxation, and I am encouraged to consult a tax professional regarding the taxability of payment from this program. A W-9, Internal Revenue Service (IRS) Form will need to be submitted prior to release of the incentive funds. If I am awarded the incentive, I understand that the payment information will be forwarded to both the State of California and the United States Treasury and an IRS Form 1099 will be issued. I understand that a fully functional hour meter/odometer will be required on the new vehicle/equipment and that the hour meter/odometer will record the annual hours/miles accumulated for which this information will be reported to the District for the term of the Agreement. I understand that District staff will evaluate this application and determine if it meets the eligibility requirements I understand that I must be in compliance and remain in compliance with all applicable federal, state, and local air quality rules and regulations. Application Statement Please Read All information provided in this application will be used by the Yolo-Solano Air Quality Management District (District) to evaluate the eligibility of this application to receive incentive funds. District staff reserves the right to request additional information of the applicant and can deny the application if such requested information is not provided. Incomplete and illegible applications will not be accepted. An incomplete application is an application that is missing information critical to the evaluation of the project. If the applicant does not respond within 30 days, the application will be automatically terminated and the application process will have to be re-initiated in order for the project to be considered. I certify to the best of my knowledge that the information contained in this application is true and accurate. I agree to accept the evaluation performed on my application by the District staff and that I can request that District staff review that evaluation upon a reasonable request. I understand that all technologies must either be verified or certified by CARB to reduce Oxides of Nitrogen (NOx) and/or other criteria pollutants. I understand that there may be conditions placed upon receiving an incentive and agree to refund the incentive if it is found that at any time I do not meet those conditions and if directed by the District. I understand as a participant that programs have limited funds and shall terminate upon depletion of program funding. The District shall be under no obligation to honor requests received following depletion of program funding. I acknowledge that in accepting any incentive funding, I will be prohibited from applying for any other form of emission reduction credits, including: Emission Reduction Credit (ERC); Mobile Emission Reduction Credit (MERC) and/or Certificate of Advanced Placement (CAP), for all time, from the Yolo-Solano Air Quality Management District, CARB or any other Air Quality Management or Air Pollution Control District. In the event that the vehicle(s)/equipment do not complete the minimum term of any agreement eventually reached from this application I agree to return to the District a pro-rated portion of incentive received based on usage up to and including the full amount of the original incentive provided as directed by the District. I understand that the Air Pollution Control Officer for the Yolo-Solano Air Quality Management District may relieve this obligation to return the funds depending on the circumstances. I have the legal authority to apply for incentive funding for the entity described in this application. I agree to the above statements by signing below. Authorized Signature Authorized Representative s Name (print) Date Title (print) Yolo-Solano Air Quality Management District Application Page 2 of 5 08/2014

3 Equipment Information Form (Please type or print neatly) Vocation/Duty of Vehicle/Equipment: Vehicle/Equipment (check one): Off-road On-Road School Bus: Project Type (check all that applies): Equipment Replacement (New or Used Vehicle) Engine repower New lower-emission equipment Incremental lower emission fuel cost Engine retrofit other: Main Physical Vehicle/Equipment Location (No PO Boxes) GPS UTM coordinates OR, City, State, and Zip Code Main Counties of Operation Annual Vehicle/Equipment Usage Information in Hours or Miles over the Last 3 Years (attach copy) Select One Miles Hours Within District Outside District May Oct Nov Apr May Oct Nov Apr Existing Vehicle/Equipment Information Make: Model: Model Year: GVWR: Vehicle Identification Number: Fleet Identification Number: License Plate: Odometer: Truck Body? No Yes (if yes, describe body type): Existing Engine Information Make: Model: Model Year Serial Number: HP: Hour Meter: Fuel Type: Engine Family Number: Emission Tier (if applicable): Engine previously & currently in daily operation? Yes No (if no, explanation is required): New or Replacement Vehicle/Equipment Information (provide information below and attach written quotes/estimates) Make: Model: Model Year: GVWR: Vehicle Identification Number: Fleet Identification Number: License Plate: Odometer: New Engine or Retrofit System Information (provide information below and attach written quotes/estimates) Make: Model: Model Yr: Serial Number: HP: Hour Meter: Fuel Type: Engine Family Number: Emission Tier (if applicable): For Retrofits ONLY: CARB EO#: NOx Reduction Mark/Percent Reduction: PM Reduction Level: Requested Funding Amount for this vehicle/equipment: Requested Contract Life (years): Yolo-Solano Air Quality Management District Application Page 3 of 5 08/2014

4 Project Usage and Cost Information: Please attach copies of all applicable items: Existing (Old) Vehicle/Equipment Documentation of Annual Mileage/Hours of Operation for last 2 years Current On-Road DMV Registration and Title/Off-Road Ownership Documentation New Vehicle/Equipment: Vender/Dealer Price Quote and Warranty for New Vehicle(s)/Equipment or Engine (Repower) /Retrofit (Include Vendor Name and Contact Information) Vehicle/ Engine Specifications Sheet and CARB Executive Order Copies of all participant cost share documents must be submitted the District with the final claim(s) prior to reimbursement. Valid cost share documents include detailed dealer payment receipt(s); copies of the processed applicant payment check and/or associated financing documents. Destruction of Existing Equipment Existing equipment that is being replaced must be sent to a District -approved salvage yard for destruction after the new vehicle/equipment has been delivered and a post and salvage inspection has been completed by the District prior to payment of the approved incentive amount. NO part of existing equipment can be re-used or kept by the applicant. Cost Share Resources: Identify All Anticipated Cost Share Resources: 1 Participant Cash Payment $. 2 Participant Financing (including all loans & leases) $. 3 Participant Tax Credits (excluding depreciation) $. 4 Other Assistance: $. 5 Total Participant Cost Share (Line ) $. 6 Requested Incentive Program Amount (from Page 3) $. 7 Total Project Cost (Line 5+6) $. Public Agency Fleet and Regulatory Information if Applicable (Non-Agricultural Only) Public Agency Fleet Size under CARB On-Road Public/Utility Fleet or Off-Road Regulation: Please check: Small Medium Large Retrofit/BACT Compliance Date for Subject Vehicle/Equipment: (Vehicle must be in compliance with all applicable fleet regulations) Two-Party Check: If you are requesting a two-party check under Payment Request Option 2 or 3 (on page 1), note the vendor and address, if applicable below. Option 2: Vendor Name: (Check mailed to Applicant) Option 3: Vendor Name: (Check mailed to Vendor) : Street City State Zip Code Yolo-Solano Air Quality Management District Application Page 4 of 5 08/2014

5 In addition to other factors, the incentive amount will be based on the vehicle or equipment s annual miles or hours of operation that have taken place within District boundaries as shown below: The District boundaries include all of Yolo County and the northeastern portion of Solano County. The Solano boundary extends from I-80 eastward along the southern boundary of the California Medical Facility, which corresponds to Hay Road. Southerly, it extends to Goose Haven Road toward the vicinity of Birds Landing and Montezuma Hills Road; it then goes easterly 3/4 of a mile south of Montezuma Hills Road to the intersection of the Sacramento River. Yolo-Solano Air Quality Management District Application Page 5 of 5 08/2014