Heavy-Duty Vehicle and Equipment Grant Program Stationary Equipment Replacement Application Form 1. Applications with altered language or forms will be void. 2. The maximum cost per ton of NOx reduced for stationary replacement equipment projects is $10,000. Applications may be selected for funding on a competitive basis and projects with a lower cost per ton may have a greater chance of selection. ELIGIBLE COUNTIES Collin, Dallas, Denton, Ellis, Johnson, Kaufman, Parker, Rockwall, and Tarrant Counties Application Deadline: Projects will be selected on a modified first-come-first-served basis with proposals scored and selected in one- week intervals. Applications are due to NCTCOG offices by 5:00 p.m. Central Time each Friday through March 26, 2010 June 25, 2010 or until funds are fully awarded, whichever occurs first. North Central Texas Council of Governments Air Quality Policy and Program Development 616 Six Flags Drive Centerpoint Two Arlington, TX 76011 (817) 608-2328 www.nctcog.org/trans/air/programs/terp/hdvegp (Based on TCEQ's Emissions Reduction Incentive Grant Forms 10430) ON-ROAD REPLACEMENT APPLICATION Application Instructions This application is to be used to apply for funding through the Heavy-Duty Vehicle and Equipment Grant Program (HDVEGP) administered by North Central Texas Council of Governments (NCTCOG). Project eligibility criteria and types of purchases eligible under this program are explained in the NCTCOG's Call for Projects (CFP) document, which can be found at www.nctcog.org/trans/air/programs/terp/hdvegp. Applicants should review this document before completing this application. HOW TO APPLY: 1. Complete the Stationary Equipment Replacement Application Form. The application must be signed and dated. 2. For multiple vehicles, complete and attach separate pages 5 through 10 (the red highlighted tabs) for each vehicle to be funded. Please note: •Applications must be typed or completed in blue or black ink. ▪All forms must be legible and unaltered. Application forms that are altered will not be accepted. 3. Attach all required attachments (see below). Please note that NCTCOG may request additional materials to support the application. 4. Submit two (2) copies (with original signature) of the completed application to: North Central Texas Council of Governments Attn: Amanda Brimmer 616 Six Flags Drive Centerpoint Two Arlington, TX 76011 PLEASE NOTE: • Applications will not be accepted for an activity that was previously awarded a grant from NCTCOG or Texas Commission on Environmental Quality (TCEQ) that was subsequently canceled by the grant recipient after the date of issuance of this CFP. EXCEL INSTRUCTIONS: Each of the forms is on an individual Excel worksheet within a Workbook. Use the tabs located at the bottom of the worksheet to access each form. PRINTING FROM EXCEL: In order to print all the pages located in the workbook, please follow these directions: (1) Click on "File" (2) Click on "Print" (3) Under the "Print What" section, select "Entire Workbook" APPLICATION PROCESSING: ▪After the weekly close date of the application period (5:00 p.m. each Friday), NCTCOG staff will review all received grant applications. The applicant will be notified if any additional information is needed or if there are any discrepancies. Applications will then be scored and ranked according the process listed in the CFP. ▪This is a reimbursement program and applications may be considered in a competitive manner. Submission of an application does not guarantee grant funding. ▪ For replacements, the make, model, and manufacture year of the engine that you purchase may differ from the information originally listed in the application. However, in all cases, the engine purchased must be certified to the federal NOx emissions standard that corresponds to the Engine Emissions Model Year listed. Finally, you may not substitute the equipment and/or engine being replaced with a different unit. PUBLIC INFORMATION NOTICES: If you have questions on how to fill out this form or about the Heavy Duty Vehicle and Equipment Grant Program, please contact us at 817-608- 2328 Upon submission, all proposals become the property of NCTCOG and as such become subject to the Texas Public Information Act, Texas Government Code, Chapter 552. Personal Information Policy: Individuals are entitled to request and review their personal information the agency gathers on its forms. They may also have any errors in their information corrected. To review such information, contact NCTCOG at 817-608-2328. REQUIRED DOCUMENTS ATTACHED: (These materials must be included with the Replacement forms.) If the replacement equipment has not yet been purchased, submit three (3) written bids/quotes for the purchase. If the final quote has not yet been obtained, provide any preliminary quotes or other information to verify the estimated cost of the replacement equipment. For lease-to-own or financing arrangements, the quotes must include the cash basis used to determine the amounts, and full details of the terms of the agreement. If the replacement equipment has already been purchased, provide the purchase, lease, or financing agreement and/or invoice showing the price paid. Two photographs depicting an overall picture of the equipment and of the engine. HEAVY-DUTY VEHICLE AND EQUIPMENT GRANT PROGRAM Specific Eligibility Criteria Specific Eligibility Criteria for Stationary Equipment Activities ▪ Not less than 75 percent of the annual usage of the equipment for the projected activity life must take place in the eligible counties. ▪ Stationary equipment powered by a 25 horsepower (hp) or greater engine is eligible for funding consideration. ▪ A project may not exceed $10,000 per ton of NOx emissions reduced in the eligible counties. Individual activities included under a single project may exceed this amount, but the combined projected total must be equal to or less than $10,000 per ton. ▪ For replacement projects, the proposed usage commitment can not exceed the annual average usage over the past 24 months and no more than 80 percent of the eligible incremental costs of each activity may be reimbursed. ▪ If the grant-funded equipment will be acquired and used under a lease or a lease-purchase agreement, the period of the lease agreement must extend for at least the Activity Life or, if the lease terminates before the end of the Activity Life, the lease agreement must include a binding commitment for the grant recipient to pay any remaining costs and to take ownership of and title to the equipment. An option to buy at the end of the lease term, without a binding commitment on the part of the grant recipient, will not be sufficient to satisfy this provision. ▪ Equipment used primarily for competition or recreational purposes are not eligible for funding. ▪ The NOx emissions of the reduced-emission technology and/or the percentage reduction in the baseline NOx emissions must be certified or verified by the U.S. Environmental Protection Agency (EPA) of the California Air Resources Board (CARB). ▪ In instances where two technologies are combined on the same engine, NCTCOG may consider the combined reductions from the two technologies in meeting the 25 percent reduction requirements. This decision will be solely at the discretion of NCTCOG. Combining a qualifying fuel technology with a different technology will not normally be considered a permanent reduction to meet the 25 percent reduction requirement. ▪ An activity is not eligible if it is required by any state or federal law, rule, regulation, memorandum of agreement, or other legally binding document. ▪ The incremental cost must be reduced by the value of any other financial incentive to be used to directly offset some of the cost, including tax credits or deductions, other grants, or any other public financial assistance. NCTCOG - Heavy-Duty Vehicle and Equipment Grant Program HEAVY-DUTY VEHICLE AND EQUIPMENT GRANT PROGRAM Program-Specific Certifications and Assurances By signing this application, the applicant indicates their understanding of and agreement to adhere to the identified program-specific requirements. The applicant hereby assures and certifies compliance with all state statutes, regulations, policies, guidelines, and requirements as they relate to the application, acceptance, and use of funds for this project. The applicant further understands, assures and/or certifies that: 1 To the best of its knowledge, the proposed activities are not required by any state or federal law, rule, or regulation, memorandum of agreement, or other legally binding document. 2 It understands that any marketable nitrogen oxides (NOx) and volatile organic carbon (VOC) credits under state or federal emissions reduction credit averaging, banking, or trading programs, that may be generated by the proposed activities, are transferred to the state implementation plan or permanently retired, and may not be used by the applicant. If the project is funded, the applicant waives, for all time, its right to claim NOx and VOC emissions reduction credits which may accrue during the activity life as a result of the use of the low-emission technology which is funded under this program, and agrees not to apply for any such credits based on reductions generated in the eligible counties. NOx and VOC credits that accrue after the end of the activity life are not transferred, but may not be used to calculate the cost- effectiveness of the project. 3 All public financial incentives that will be used by the applicant that directly offset the costs of the proposed activities, including tax credits or deductions, other grants, or any other public financial assistance have been properly listed where indicated on the application forms and the incentive amounts requested reflect a reduction in the eligible incremental costs based on the value of those incentives. 4 It understands that failure to achieve the NOx emissions reductions projected to be achieved for this project may result in NCTCOG requiring the return of all or a share of the grant funds. Achievement of the emission reductions will be based on the grant equipment being used for the annual amount of hours, miles, or fuel use that occurs in the eligible counties, as designated in the application for that activity. 5 It understands that failure to operate the grant equipment for the annual usage and percentage of annual use in the eligible counties as designated in the application may be considered non-compliance with the grant agreement and may result in NCTCOG requiring return of all or a share of the grant funds. 6 It will monitor the use of grant-funded vehicles, equipment, infrastructure, or qualifying fuel, and report semi-annually to NCTCOG over the designated activity life. 7 It will notify the NCTCOG of any termination of use, change in use, sale, transfer, or destruction of grant- funded vehicles or equipment, or change in use of qualifying fuel, during the activity life. It further agrees that, during the activity life, the NCTCOG may be entitled to the return of all or a share of the grant funds for any loss of emissions reductions compared with the emissions reductions projected in awarding the grant. 8 It will maintain, for the term of the activity, property loss insurance or self-insurance coverage on any vehicles, equipment, or infrastructure acquired, leased, repowered, retrofitted, or constructed using these funds, sufficient to cover the costs of reimbursing the state for its pro rata share of the activity costs. HEAVY-DUTY VEHICLE AND EQUIPMENT GRANT PROGRAM General Certifications and Assurances This section serves to assure NCTCOG that you understand and agree to the statements. These provisions relate to the basic contract form which will be in force between the applicant and NCTCOG upon award of a grant. NCTCOG is under contract with TCEQ for administration of this program. The applicant agrees to apply with any and all statutory requirements of this program as if the applicant were contracting directly with TCEQ. NCTCOG urges applicants to download a copy of the example grant contract from www.nctcog.org/trans/air/programs/terp/hdvegp and review it so that any questions can be discussed early in the application review process. By signing this application, the applicant assures and certifies that: 1 Legal Authority. It possesses legal authority in the State of Texas to apply for the grant and that the applicant's governing body has authorized the filing of the application, including all understandings and assurances contained therein, and directing and authorizing the person identified as the authorized official to act in connection with the application and to provide such additional information as may be required. 2 Uniform Grant Management Standards. It will comply the Uniform Grant Management Standards (UGMS), adopted by the Texas Office of the Governor, in accordance with Chapter 783, Texas Government Code. 3 Procurement of Goods and Services. In procuring goods and services, it will comply with Part II. Cost Principles for State and Local Governments and Other Affected Parties and Part III. State Uniform Administrative Requirements for Grants of the UGMS. All procurement transactions will be conducted in a manner providing full and open competition. 4 Historically Underutilized Businesses (HUBs). Qualified HUBs, as defined and designated under state law, shall have the maximum practicable opportunity to participate in the performance of the work arising out of this project. 5 Conflict of Interest. Applicant has not given, offered to give, nor intends to give at anytime hereafter, any economic opportunity, future employment, gift, loan gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted application. Under Government Code § 2155.004, no person involved in the preparation of the Call for Projects may have any financial interest in this application. If applicant is not eligible, then any contract resulting from this application shall be immediately terminated. Furthermore, under Section 2155.004, Government Code, the applicant certifies that the individual or business entity named in this bid or contract is not ineligible to receive the specified contract and acknowledges that this contract may be terminated and payment withheld if this certification is inaccurate. 6 Nondiscrimination. It will comply with all State and Federal statutes relating to nondiscrimination. 7 Grant Administration. It will maintain an appropriate grant administration system to ensure that all terms, conditions, and specifications of the grant, including these certifications and assurances, are met. 8 Audit. Pursuant to Section 2262.003 of the Texas Government Code, NCTCOG and/or the state auditor may conduct an audit or investigation of the vendor or any other entity or person receiving funds from the state directly under this contract or indirectly through a subcontract under this contract. The acceptance of funds by the applicant or any other entity or person directly under this contract or indirectly through a subcontract under this contract acts as acceptance of the authority of the state auditor, under the direction of the legislative audit committee, to conduct an audit or investigation in connection with those funds. Under the direction of the legislative audit committee, the applicant or other entity that is the subject of an audit or investigation by the state auditor must provide the state auditor with access to any information the state auditor considers relevant to the investigation or audit. Applicant will ensure that this clause concerning the authority to audit funds received indirectly by subcontractors through the vendor and the requirement to cooperate is included in any subcontract it awards. 9 Debt to the State. It is not indebted to the state or have an outstanding tax delinquency. It further understands that the Texas Comptroller is precluded by law from paying a person who is indebted to the state or has a tax delinquency. The applicant must comply with all State and Federal tax laws and fee requirements and is solely responsible for filing all State and Federal tax and fee forms. 10 Grant Contract. It understands that a copy of the grant contract shell is available from the NCTCOG, including a copy posted on the NCTCOG's web site at www.terpgrants.org. It further understands that the NCTCOG will not normally change the contract language to deal with individual requests from grant recipients. 11 Contracting with an Executive of a State Agency. Under Government Code § 669.003, relating to contracting with an executive of a state agency, Applicant represents that no person who, in the past four years, served as an executive of the TCEQ or any other state agency, was involved with or has any interest in this Application. If Applicant employs or has used the services of a former executive head of TCEQ or other state agency, then Respondent shall provide the following information: Name of former executive, name of state agency, date of separation from state agency, position with Applicant, and date of employment with Applicant. 12 Debarment. Applicant certifies that the applying entity and its principals are eligible to participate in this transaction and have not been subjected to suspension, debarment, or similar ineligibility determined by any federal, state or local governmental entity and that Respondent is in compliance with the State of Texas statutes and rules relating to procurement and that Respondent is not listed on the federal government's terrorism watch list as described in Executive Order 13224. Entities ineligible for federal procurement are listed at http://www.epls.gov. 13 Hurricane Katrina and Other Natural Disasters. Under Section 2155.006(b) of the Texas Government Code, a state agency may not accept a bid or award a contract, including a contract for which purchasing authority is delegated to a state agency, that includes proposed financial participation by a person who, during the five-year period preceding the date of the bid or award, has been: (1) convicted of violating a federal law in connection with a contract awarded by the federal government for relief, recovery, or reconstruction efforts as a result of Hurricane Rita, as defined by Section 39.459, Utilities Code, Hurricane Katrina, or any other disaster occurring after September 24, 2005; or (2) assessed a penalty in a federal civil or administrative enforcement action in connection with a contract awarded by the federal government for relief, recovery, or reconstruction efforts as a result of Hurricane Rita, as defined by Section 39.459, Utilities Code, Hurricane Katrina, or any other disaster occurring after September 24, 2005. Under Section 2155.006 of the Texas Government Code, the bidder certifies that the individual or business entity named in this Application is not ineligible to receive the specified contract and acknowledges that any contract resulting from this IFB may be terminated and payment withheld if this certification is inaccurate. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 1 - Signature Page 1. Applicant/Company Name: Please note: The applicant must be the owner of the vehicle. Authorized Official: Applicant or an employee of the applicant authorized to apply for the grant I hereby certify that to the best of my knowledge and belief all information provided in this application and any attachments is true and correct. If the application was prepared by a third party, I certify that I have read the complete application after all forms and information were completed, I agree with the information provided, and the date provided below is the date I signed the form. I further understand that prior to incorporating these forms and information into a grant contract the data and information may be revised by NCTCOG for accuracy and that our acceptance of a grant contract will constitute agreement with those revisions. Failure to sign the application or signing it with a false statement may make the submitted offer or any resulting contracts voidable. Signature of Authorized Official (the individual authorized to execute a contract with NCTCOG to implement this project): PLEASE SIGN IN BLUE OR BLACK INK. Faxed or photocopied signature pages will not be accepted. The application, with an original signature, must be received by 5 p.m. Central Time of each Friday in order to be considered with that week's applications. Printed Name of Authorized Official: Authorized Official's Title: Date of Signature (must be the date the form was signed in blue or black ink ): Was this application substantially completed or otherwise prepared by a third party, including a consultant, dealer, or other person not employed by the applicant? Check either "yes" or "no" below. Yes No If "yes" then the preparer must sign below. Please sign in BLUE OR BLACK ink. I hereby certify that to the best of my knowledge and belief all information provided in this application and any attachments is true and correct, as represented to me by the applicant. I understand that failure to sign the application or signing it with a false statement may make the submitted offer or any resulting contracts voidable. Signature of Third-Party Preparer Printed Name (include Mr. or Ms.) Title Company Name Address Phone Number Date of Signature (in ink) By signing the application Signature Page, the applicant certifies that the applicant is the current owner of the vehicle or equipment being purchased. Ownership does not include leases. If you have questions on how to fill out this form or about the HDVEGP, please contact us at 817-608-2328. Upon submission, all proposals become the property of NCTCOG and as such become subject to the Texas Open Records Act, V.T.C.S. art. 6252-17a. Personal Information Policy: Individuals are entitled to request and review their personal information that the agency gathers on its forms. Individuals may also have any errors in their information corrected. To review such information, contact the HDVEGP program at 817-608-2328. Do NOT alter forms. Altered forms will be void. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 2 - Applicant Information 2. Applicant/Company Legal Name for Contracting Purposes: Applicant must be the owner of the equipment. If the applicant is a company, the company (not the individual owning the company) must be the owner of record of the equipment. 3. Payee Identification Number (PIN): Indicate the type of number you are providing to be used for your PIN. Provide only one (1) of the following numbers. Do not complete both A and B. A. Only complete if you are applying as an individual. Social Security Number (SSN): OR B. Only complete if you are applying as a company or other entity, including DBA's (Doing Business As). Federal Employer Identification (FEI) Number: 4. Is the applicant currently reporting any Texas tax to the Comptroller's Office other than unemployment (e.g., sales tax, franchise tax)? Yes, enter Texas Taxpayer Number No 5. Mailing Address for Grant Payments : Include individual or entity name, address, city, state, and zip code. (Name) (Address) (City) (State) (Zip) 6. Ownership Codes: Check only one (1) ownership type that applies to this application and matches the legal name. I - Individual Recipient (not owning a business) J - Joint Venture S - Sole Ownership (individual owning a business) L - Limited Partnership Owner's Name: Texas File #: Owner's SSN: T - Texas Corporation / Limited Liability Corporation Texas Charter #: P - Partnership, if checked, enter two partner's A - Professional Association names and Social Security Numbers (SSN). If a Texas Charter #: partner is a corporation, use the corporation's Federal Employer's Identification (FEI) Number. C - Professional Corporation Name: Texas Charter #: SSN/FEI#: O - Out-of-State Corporation G - Governmental Entity Name: U - State Agency/University SSN/FEI#: R - Foreign (outside of USA) N - Other (explain): 7. Date of Clean Fleet Policy Adoption OPTIONAL : (only applicable for public entities) Please note, public entities seeking funding are encouraged to adopt the Regional Transportation Council's Clean Fleet Vehicle Policy. For more information, please visit www.nctcog.org/fleetpolicy. 8. Do you plan to assign your grant payments to a third party "Assignee": Yes No If "yes", you must submit a completed "Notice of Assignment" and a "Texas Application for Payee Identification Number (AP-152)". These forms will be provided for you to complete and submit if you are awarded a grant. 9. Describe Applicant's Primary Business Type: (i.e., transit system, gravel hauling, excavation, school, etc.) 10. Date Business Founded/Started: Attach any materials (ex: brochures, Web site address) that provide general information about your business. 11. Number of Activities (if submitting multiple vehicles): Each replacement will require a separate Activity Application Tab Set. (pages 5-8) 12. Total Project Grant Amount Total Incremental Cost of the Project (total from section 26D 29D for all activities) $ Total Grant Amount Requested (total from section 27 30 for all activities) $ Grant amounts may be taxable. Consult your tax professional. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 3 - Contact Information 13. Authorized Official (The individual who is authorized to execute a contract with NCTCOG to implement this project. This must be the same person that signs the application.) Name: (Mr. or Ms.) Title: Mailing Address: Street Address City State Zip Physical Address: (for express delivery) Street Address City State Zip Contact Phone #s: Fax: E-mail: 14. Designated Project Representative (The applicant or an employee of the applicant who will serve as the grant contact and will be responsible for receiving and submitting grant documents, including annual usage reports. This person may not be a consultant or dealer.) Same as Authorized Official Name: (Mr. or Ms.) Title: Mailing Address: Street Address City State Zip Physical Address: (for express delivery) Street Address City State Zip Contact Phone #s: Fax: E-mail: 15. Financial Officer (if applicable) Same as Authorized Official Name: (Mr. or Ms.) Title: Mailing Address: Street Address City State Zip Physical Address: (for express delivery) Street Address City State Zip Contact Phone #s: Fax: E-mail: 16. Designated Location for Records Access and Review by NCTCOG, TCEQ, or a Representative Physical Address: Street Address City State Zip STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 4 - Certifications All individuals or business entities, including sole proprietors must complete this section, regardless if child support obligations apply to the applicant. 17. Certification Regarding Child Support Obligations Under Section 231.006, Texas Family Code, a child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25 percent is not eligible to receive a State-funded grant or loan. All applicants must include in the application the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of 25 percent of the business entity submitting the application, as required by Texas Family Code 231.006(c). Please check one of the options below. If the first option is checked, list the Name and Social Security Numbers of any individual who owns 25 percent or more of the business entity submitting this application, regardless if child support obligations apply to that individual. Check if the applicant is an individual or sole proprietorship, or if one or more individuals own 25 percent or more of the business entity. List the names and social security numbers (SSN) below. Name: SSN: Name: SSN: Name: SSN: Name: SSN: Check if there is not a single individual who owns 25 percent or more of the business. Check if the applicant is not an individual or business entity. I certify that to the best of my knowledge and belief that the individual or business entity submitting this application is eligible to receive a grant. I acknowledge that the grant contract may be terminated and any payments withheld if this certification is inaccurate. Signature of Authorized Official: Date (in ink): STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 5 - General Activity Information 18. Has this activity been included in a previous application to NCTCOG or TCEQ? Yes, please explain & include date: No Activities that were previously awarded an NCTCOG or TCEQ grant and canceled by the grant recipient after the open date of this application period are not eligible to receive funding. 19. Has the purchase already been completed? Yes Date of purchase: No Expected # of months to complete the purchase: The purchase may not have been made prior to the open date of this application period. 20. Designated Activity Life The number of years you commit to using the vehicle in the eligible counties and to monitor and report to NCTCOG on the use. (7 year Activity Life Required for Stationary Equipment Replacement Activities) Activity Life 7 years 21. Is the equipment being used for commercial rental to other entities? Yes, please explain: No 22. Hours of Operation How many hours do you commit to operate per year over the Activity Life? this amount may not exceed, but may be less than, the average annual hours of operation per year over the last two years. (per year) Over the last two years, how many hours have you operated the equipment on average per year. (Must be the same as entered on page 14). DO NOT overstate your historical average annual use. (per year) 23. Site Location and Permitting Stationary sources may be subject to TCEQ permitting regulations. List the specific physical location at which the equipment will be operated. If the applicant and/or site is regulated by TCEQ in the areas identified in question 24, provide the permit, project, registration, and/or account number. A. Physical Address and/or Other Description of the Location: Check if the site is NOT covered by a permit B. Name of Permit Holder: TCEQ Permit/Project/Registration/Account Number (if applicable) : General Permit or Permit by Rule (if applicable) : List permit or rule number and provide a summary of equipment regulated. By signing this application, the applicant certifies that the NOx emissions reductions achieved by this activity are not already required under the conditions of a permit or rule for this site or to ensure that the site or facility remains under an emissions limit. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 6 - General Activity Information The calculation of emissions reductions is partially based on the percentage of use in the eligible counties. If you do not use the grant funded equipment for the committed percentage of time in the eligible counties, NCTCOG may require a refund of all or a portion of grant funds. All projections should be realistic. The applicant will be held accountable for meeting the usage commitments. 24. Project Area and Annual Usage Commitment The applicant must designate in the application the percentage of usage that will occur in the eligible counties, which may not be less than 75 percent of the annual usage. Usage outside of the eligible counties will not count towards the 75 percent requirement. % OF ANNUAL USAGE SPENT OPERATING IN THE ELIGIBLE AREAS Please note: This section may not equal 100 percent if the equipment is used in a county not listed below. Dallas - Fort Worth Area (DFW) % (Collin, Dallas, Denton, Ellis, Johnson, Kaufman, Parker, Rockwall, Tarrant) List all other counties/states in which you plan to operate below, including counties between the eligible areas listed above. % TOTAL ANNUAL USAGE 100 % Please Note: Applicants are cautioned against overstating the historical and/or projected annual usage (hours of operation, and/or fuel use) and the percentage of that usage in eligible counties in order to qualify for a grant. The grant contract will require the return of a share of the grant funds if the annual usage targets and the percentage of that usage in the eligible counties are not met. Semi-annual monitoring reports will be required and NCTCOG may periodically conduct site visits to verify that the information provided is correct. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 7 - Equipment Information 25. VEHICLE Equipment Being Replaced New Equipment INFORMATION a. Equipment Description (must be the same type) (i.e., agricultural and compressor pumps, generators, etc.) b. Equipment Make c. Equipment Model / Model Number d. Equipment Model Year (if known) e. Equipment Identification Number f. Engine Make g. Engine Model / Model Number (if known) h. Engine Identification # i. Engine Model Year j. Engine Horsepower Must be equal to or greater than 25 hp k. Fuel Type If dual fuel, list each type (may not be available for pre-2000 equipment) l. Engine Family Code 12-digit emissions code (if known) (if known) m. Certified NOx Emissions (g/bhp-hr) * Refer to the stationary equipment NOx emissions standards applicable to the year of the engine in NCTCOG's Stationary Equipment calculator. However, if either the current engine or the replacement engine are certified to a different NOx emissions rate than the standard that applies to the year of the engine, list the correct NOx emissions rate. You must check with your dealer or installer to confirm the NOx emissions certification of the replacement engine. 26. DISPOSITION OF STATIONARY EQUIPMENT/ENGINE BEING REPLACED The old equipment and engine must be scrapped (destroyed). The applicant agrees to destroy and render permanently inoperable the old equipment, including the engine within 90 days of receiving financial reimbursement new equipment being placed into service. The applicant also agrees that TCEQ may inspect and otherwise verify the condition of the equipment and engine being replaced. If the applicant does not allow such verification, the TCEQ is not obligated to select the application for funding. Destruction includes drilling a three-inch or larger hole in the engine block (or otherwise destroying it) and cutting the frame rails or structural components in a wedge at least 75 percent of the way through (or perform other structural damage to the equipment) rendering it inoperable. Provide information regarding the scrappage activities and, if known, identify (name, address, and phone #) the company that will scrap the equipment. Please note: If a grant is awarded, the applicant will be required to submit the following information with the final disposition of the equipment/engine: ▪ Photographs depicting the equipment/engine BEFORE and AFTER destroying/rendering it inoperable. ▪ Photographs must show the engine identification number, and they must be clearly visible and readable. STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 8 - Equipment Information 27. APPLICANT CERTIFICATION OF OWNERSHIP, USE and CONDITION The applicant assures and certifies to all of the following information. Please check each item below to certify that the application meets these conditions and provide the requested information. Sign below to certify to that these conditions are met. A. The applicant has owned the equipment being replaced for at least the two years preceding the submission of this grant application. NCTCOG may waive the two year ownership requirement on a case-by-case basis in instances where the ownership of the company has changed, the assets of the company have been purchased by another company, or the company has changed names or incorporation status. The use of the equipment being replaced may not have changed. Attach an explanation. Date of purchase of the equipment being replaced: Location of purchase: B. The equipment being replaced has been used in Texas for at least the two years preceding the submission of this grant application C. The equipment being replaced is in operating condition, meaning that the engine runs normally and the equipment is currently capable of performing the functions for which it is intended. Do not apply if the engine and/or equipment are not currently in operating condition. D. The equipment being replaced would have otherwise continued to be used within the eligible counties for the same or similar purposes for at least the selected Activity Life. The following section must also be complete. If the hour meter is not working or has been replaced, provide an estimate. E. The equipment being replaced has total hours indicated on the meter or use logs. Is the meter working (Y/N): F. Equipment Being Replaced: The average annual operating hours over the past two years: hours each year. DO NOT overstate the historical average annual use of the equipment being replaced. Please sign below in BLUE OR BLACK ink. I hereby certify that to the best of my knowledge and belief this application meets the conditions listed above and the information provided is true and correct. Signature of Authorized Official: Date (in ink): STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 9 - Equipment Information 28. EQUIPMENT CERTIFICATION This form is to be completed and signed by a certified mechanic or a service agent qualified to assess the condition of the vehicle or equipment. The service agent may not be the consultant or an employee of the applicant, unless otherwise approved by NCTCOG. INFORMATION ON THE EQUIPMENT BEING REPLACED Equipment Make / Model: Equipment Identification Number: Note: The VIN or Identification number must match the number listed on Page 11. SERVICE AGENT INFORMATION: (do not complete if the vehicle/equipment is not operating) I, the undersigned, have inspected the equipment noted above. The engine starts and runs properly and the equipment is in good operating condition. In my professional opinion the equipment is able to perform the functions normally expected for this type of vehicle/equipment and could be expected to operate for an additional 5 to 7 years. Printed Name: Name of Service Company: Phone Number: Address: List qualifications to assess condition of the vehicle or equipment (i.e., certified mechanic, etc.) Date: Service Agent Signature: (in ink) STATIONARY EQUIPMENT REPLACEMENT APPLICATION Page 10 - Activity Cost Refer to the Call for Projects document for a full list of eligible and ineligible expenses. Applicant's 29. INCREMENTAL COST / COST TO APPLICANT (A-B-C = D) Cost A. Capital Cost - Equipment Purchase: $ Invoice cost or cash basis for the lease cost of the vehicle, including taxes, duty, (- SUBTRACT) protective in transit insurance, and freight charges. B. Scrappage value: NCTCOG will use a default scrap value of $1,000 $ 1,000.00 (- SUBTRACT) C. List the value of and explain any other financial assistance to be used for the $ purchase or lease, such as tax credits or deductions, other grants, or any other public financial assistance: This does not include the amount you finance through a bank or other third-party to purchase the equipment. D. Incremental Cost / Cost to Applicant (A-B-C = D) $ (Please refer to on-line calculator for assistance determining this value) 30. GRANT AMOUNT REQUESTED FOR THIS ACTIVITY Please Note: This amount may not exceed 80% of the Incremental Cost or and $ $10,000 per ton of NOx reduced 31. DEALER CONTACT INFORMATION (if known) (Company) (Contact Person) (Phone #) (Address) (City) (State) (Zip) 32. FINANCING OR LEASE TERMS FOR REPLACEMENT VEHICLE Reimbursement will not be authorized for pre-payment of future periodic financing or lease payments. A grant recipient will need to either ensure that sufficient payments will be made prior to the end of the grant term to use the grant amount or structure the financing or lease agreement to allow for an up-front payment in return for lower periodic payments. CHOOSE ONE: Purchase: Cash Purchase Regular Financing Capital Lease Financing (equipment will be purchased and retained at the end of the lease). This option is limited to capital lease agreements with a binding commitment for the applicant to take ownership of the equipment. An option to buy at the end of the lease term, without this binding commitment, will not be considered under this option. Lease Equipment will be returned at the end of the lease. The lease must extend for at least the Activity Life. Explain financing or lease terms, including the length (months) of the lease or financing, below: 33. PROCUREMENT PROCESS Explain the process used (or to be used) to select the dealer and the equipment. Three (3) bids or quotes are required to be attached to this grant application. If only one bid or quote was obtained, explain why the equipment is only available from one source.
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