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Transit Project Manager Contact
Before starting the application, use the Provider Notification Letter to notify your
Transit Project Manager of your intent to apply for the grant. Consult the map to
determine the appropriate TPM for your area. The letter of intent to the TPM should
be on company letterhead and mailed. Letters of intent by email will not be
accepted. Applications will be considered incomplete if the TPM is not contacted by
mail. In the Exhibit Section attach the letter of intent and label as Exhibit A.
PM should
tacted by
VEHICLE SAFETY INSPECTION FORM
The Vehicle Safety Inspection Form is to be completed for every vehicle applicant
plans to replace, regardless of original funding source. If applicant does not
propose to replace a vehicle, this form does not need to be completed.
Part I of the form reflects essential elements of the vehicle, which must be checked
by a certified mechanic;
Part II addresses vehicle components and can be completed by a qualified
employee. (A qualified employee is defined on the form.)
Safety /Risk Management Objectives/Benefits
The Federal Transit Administration (FTA) encourages all transit systems, regardless
of size, to develop and implement a proactive safety program. The Office of
Transit is committed to FTA’s Safety and Security Program.
The Vehicle Safety Inspection Form will help Mn/DOT’s Office of Transit to monitor
transit vehicle safety. Per FTA: Proper maintenance of vehicles and equipment is
critical to the continued safe operation of the transit system. Unsafe vehicles
present unnecessary hazards to the driver, passengers, and other vehicles on the
road. Basic vehicle maintenance practices should regularly address safety-related
vehicle equipment, e.g. brakes, tires, and lifts, etc. to ensure that no unsafe
vehicles are dispatched for service.
In the Exhibit Section attach the Vehicle Safety Inspection Form and label as
Exhibit B1 and B2.
Vehicle Safety Inspection Form
Mn/DOT - Office of Transit
GENERAL INSTRUCTIONS:
- Use information from the following current inspection forms to complete appropriate sections of this Form: Special
Transportation Services (STS), Commercial Vehicle Inspection (CVI), and/or Department of Public Safety (DPS).
- Transfer appropriate information from applicable inspection form(s) and attach a copy of STS, CVI and/or DPS form.
- It is the responsibility of the system to transfer applicable information from one form to the other.
- After the inspection, subtotal each column and enter the Total for Part 1 and the Total for Part 2.
- Submit completed form and attachments to Mn/DOT Transit Project Manager.
Transit System Name: ______________________________ Vehicle VIN: ____________________________
Telephone Number: ________________________________ (17 Characters)
Person Completing Form: ____________________________ Make & Year: __________________________
STS Inspection Form # ______________________________ Odometer Reading: ___________________
CVI Inspection Form # ______________________________ Date of Reading: _____________________
DPS Inspection Form #
PART 1 - To be completed by a CERTIFIED MECHANIC - ASE or equivalent:
- After each item, enter a '0' if OK; '1' if needs repair; '2' if Body/Chassis/Component deteriorating/failing
Column 1 Column 2
Engine Operation Points General Condition Points
Starting Body Exterior, Bumpers, Trim
Instrument Warning Lights and gauges Body Interior
Engine Compartment Points Chassis
Radiator Condition / Clean Suspension F / R Points
Belts / Hoses Shocks / Mounts / Bushings
Engine Air Filter / Fuel Filter Change Springs / Clamps / Shackles
Water Pump & Fan Stabilizers / Tracking Bars / Bushings
Alternator & Mounting Under Chassis Points
Battery / Terminals / Cables Frame & Subframe
Wheels Points Brake, Fuel & Coolant Lines & Hoses
Wheels (cracked, bent, etc.) Transmission / Driver Train Condition Points
Lug Nuts & Studs (loose, broken off, etc.) Fluid (eg. burnt)
Brakes Points Mounts
Pads / Rotors / Shoes / Drums U-Joints
Parking Brake Differential / Rear Axle
Fuel System Points Engine Points
Lines / Fittings (e.g. leaks, constrictions, etc.) Mounts
Tank & Mounting / Filler Cap Fluid Leakage (oil, coolant)
Steering Points SUBTOTAL
Linkage / Ball Joints TOTAL of Columns 1 & 2
Power Steering Pump / Gear Box
Exhaust System Points
Tailpipes / Hangers / Clamps / Leaks
Muffler Office Use Only
Catalytic Converter Entered by:
SUBTOTAL Initials / Date A B C
Signature of Certified Mechanic / Date n:\tra\transit\ptms\safety inspection form.xls
Exhibit A-3
PART 2 - To be completed by QUALIFIED EMPLOYEE - someone who is familiar with and trained in bus
operations, including emergency operations (e.g. operating lift without power):
- After each item, enter a '0' if OK; '1' if needs to be addressed by the operator;'2' if needs the attention of a mechanic.
Column 3 Column 4
Windows / Condition Points Safety Equipment Points
Windshield Fire Extinguisher Charge / Date
Side & Rear First Aid Kit
Doors / Operation Points Blood-Borne Pathogen Kit
Driver's Door Seatbelt Cutter
Passenger Door Reflective, Florescent Triangle Set
Lift Door Lights, Horn, Backup Alarm Points
Steps & Floor Points Interior Area / Stepwell Lighting
Clean & Free of Debris Wheelchair Lift Doorway Light
Step Treads Headlights, Switch, Low/High Beam
Loose Floor Covering Running / Brake / Tail Lights
Driver's & Passenger Seats Points Turn Signal Lights & Indicators
Mounted Firmly Hazard Flashers & Indicators
Seatbelt Operational, Clean, Not Frayed License Plate / Backup Lights
Arm Rest Loose Horn
Upholstery & Structure in Good Condition Backup Alarm
Emergency Exits Points Mirrors / Condition Points
Doors / Windows Open & Latch Properly Interior
Roof Hatch Operation (if equipped) Exterior
No Obstructions Windshield Wiper / Washer Points
Labeled Properly Wiper Blade Condition / Arm Tension
Fluids Points Wiper / Washer Switch
Engine Oil Level & Condition Washer Spray & Coverage
Coolant Level Heater / Defroster / Air Conditioning Points
Brake Fluid Level Fans Operate F / R
Power Steering Level Heaters Operate F / R
Windshield Washer Fluid Level Air Conditioner Cools Satisfactorily F / R
Transmission Fluid Level Lift / Ramp / Securements Points
Vehicle Drivability Points Lift Operation with Remote
Performance / Noise Emergency Manual Lift Operation
Speedometer / Odometer Working/Accurate Lift Interlock System
Brakes Noisy / Pulling Wheelchair Stops / Handrails
Pulls/Drifts when not Braking Restraints / Tie Downs Condition
Transmission Shifts Properly Grab Rails & Stanchions Points
Tires Points Firmly Mounted
Tread Depth / Tire Pressure Seat Mounted Grab Handles Padded Properly
SUBTOTAL SUBTOTAL
TOTAL of Columns 3 & 4
Signature of Authorized Recipient (Individual) / Date
Comments:
n:\tra\transit\ptms\safety inspection form.xls
Exhibit A-3
Service Area Map
Submit a service map of proposed route on 8 ½ “x 11” paper. Map must be
specific to the vehicle proposed use.
Use one map for each route.
Use a square and number it, to show a stop going to a destination. Use a circle and
number it, to show return stops. If a map is not available, contact the TPM.
In the Exhibit Section attach Service Area Maps and label as Exhibit C1, C2, C3 and
so forth.
circle and
2, C3 and
Local Transit System Letters
In the Exhibit Section, Attach letter(s) of response from the local transit systems
and label as Exhibit D1, D2, and so forth.
Community Support Letters
Letters of support from the community are essential to show support for project
need. It is recommended that letters of support be solicited from county and state
officials, consumer/clients, and other individuals in the community that can attest
to the importance of the service you are proposing.
In the Exhibit Section, attach letters of community support received and label as
Exhibit E1, E2, E3, E4, and so forth.
Private Non-Profit/Public Body Certification
Private Non-Profit/Public Body Certification
Circle the Letter to designate the appropriate certification for your agency and
attach required documentation. In the Exhibit Section attach this page and
required documentation and label as F1, F2, and so forth.
Section 5310 Statutory Authority:
The Federal Transit Administration's (FTA) current elderly and persons with
disabilities program is authorized by 49 U.S.C. § 5310(a)(2). Section 5310(a)(2)
authorizes the Secretary to make grants to the chief executive officer of each state
for allocation to the following eligible subrecipients:
a. Private nonprofit corporations and associations.
Private non-profit applicants are not required to be registered as a MN non-profit
corporation, but may be registered as a non-profit corporation under the laws of
other states. MN Statutes define a non-profit corporation as: “A Corporation (a)
formed for the purpose of not involving pecuniary gain to
its shareholders or members and (b) paying no dividends or other pecuniary
remuneration directly or indirectly to shareholders as such”
If applying as a private non-profit, label and attach the appropriate paperwork as:
Certified copy of certificate of incorporation, supplemented with any certificates of
amendment, merger, or consolidation, which may have been issued by the MN
Secretary of State and an IRS 501(c) letter.
b. Public bodies.
If applying as a public body, attach:
Documentation (e.g. board resolution) certifying that no non-profit
corporations or associations are readily available in the proposed area to provide
service.
Proof of public hearing: applicants must afford an opportunity for a public
hearing and hold the hearing, unless no one requests one.
Documentation that the proposed project is consistent with the adopted
transportation plans for the area.
For more information on eligible recipients, review FTA’s circular, 9070.1f, or visit
FTA’s Web site at http://www.fta.dot.gov/publications/publications_5654.html
Exhibit F 10 of 19
Public Notice and Affidavit of Publication
To ensure the general public and transportation providers are fully aware of your
proposal every applicant must publish a public notice prior to October 28, 2009.
The public notice must be published in the most frequently published newspaper in
the service area. To reduce printing costs, applicants may combine resources to
print the affidavit of publication if common service areas occur.
If the paper is printed daily, the notice must appear for three consecutive days.
If the publication is printed less than daily, only one appearance is required.
To ensure the notice is printed on time the applicant should determine publishing
deadlines for the local newspaper and be prepared to pay for publishing and for an
affidavit of publication. The public notice should state the following information:
NOTICE TO TRANSPORTATION PROVIDERS
The (name of the agency) hereby provides notice that it intends to apply to the
Minnesota Department of Transportation for the following transportation
equipment to serve elderly and persons with disabilities in (indicate the service
area). (Indicate the type of vehicle, number of seated positions, and number of
wheelchair spaces to be requested). Individuals or agencies seeking to request
transportation service, coordinate transportation with (agency name) or comment
about the application should contact (name of contact person at agency), (agency
address), (agency phone number). The deadline for submitting this application is
December 1, 2009.
In the Exhibit Section include the Affidavit of Publication from the newspaper.
Public body applicants must also attach a copy of the hearing record (if one was
requested and held) and a summary of efforts to involve the private sector to the
maximum extent feasible.
In the Exhibit Section, attach and label documentation as Exhibt G1, G2, and so
forth.
wspaper in
nd for an
(agency
Special Transportation Services (STS) Questionnaire
Applicants are required to complete the STS questionnaire. The questionnaire can
be found at:
http://www.dot.state.mn.us/cvo/applications/sts_questionnaire.pdf
The completed STS questionnaire will be forwarded to Mn/DOT’s Commercial
Vehicle Operations (CVO). CVO will make the determination if an applicant is
required to have STS certification for providing transportation service.
STS regulations found in Minnesota Rules Chapter 8840 require applicable agencies
to meet standards for vehicle operation, thereby qualifying for a certificate of
compliance. Regulations are enforced by CVO.
For more information on STS regulations go to http://www.dot.state.mn.us/cvo/ or
contact CVO directly at 395 John Ireland Blvd, MS420, St. Paul, MN 55155 or call
them at 651.215.6300.
In the Exhibit Section, attach and label the STS Questionnaire as Exhibt H1 and H2.
e agencies
or
1 and H2.
Resolution of the Governing Body
Complete a resolution for adoption by your agency’s governing board. A sample
resolution has been provided.
Mn/DOT’s policy is to have two persons identified (by title) to execute contracts
with Mn/DOT. Include a copy of the adopted resolution. The certification section of
the resolution form must bear an original signature.
In the Exhibit Section, attach and label the Resolution as Exhibt I1.
-------------------------------------------------------------------------------------------
RESOLUTION SAMPLE
Resolved that _________(applicant)__________________ enter into an
Agreement with the State of Minnesota to receive a Section 5310 vehicle to be
used to provide transportation for elderly and disabled persons;
Further resolved that ______(applicant)____________________ agrees to
provide the State with a match of 20% percent of the total vehicle cost; and
Further resolved that_____(applicant)________________ authorizes the
_______(title)________________ and/or the ___(title)__________ to execute
the aforementioned Agreement and any amendments thereto.
CERTIFICATION
I hereby certify that the foregoing resolution is a true and correct copy of the
resolution presented to and adopted by ________________________
at a duly authorized meeting held on the _______ day of, _______ 2009 as shown
by the minutes of the meeting in my possession.
__________________________
(Name)
________________________
(Title)
ection of
as shown
Copy of Agency’s Most Current Financial Statements
Attach one copy of the agency’s most current audited financial statement and Label
as Exhibit J1, J2, J3, and so forth.
and Label
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