PENNSYLVANIA STATE CLEAN DIESEL GRANT PROGRAM

PROJECT APPLICATION FY2014-2016

This form is to be used to apply for the Pennsylvania State Clean Diesel Grant Program.
Please refer to instructions and guidance/guidelines for assistance.

Based on information and belief formed after reasonable inquiry, I certify that the statements and information in this application are true and correct:

Applicant Organization:

Printed Name:

Title:

Signature:

Date: Click here to enter a date.

_____________________________________________________________________________________

Project Title (10 words maximum):

Applicant Legal Organizational Name:

DBA Name:

Mailing Address:

Applicant’s Federal Taxpayer Identification Number:

Applicant’s DUNS Number:

Applicant’s SAP Vendor Number:

Is the applicant a business with fewer than 100 full-time equivalent employees?

Yes	No

Organization type:

If Other is selected, explain here:

Is the applicant an approved distressed municipality under Act 47, Financially Distressed Municipalities Act of 1987? Yes	No

4.	Project Contact Person:

Phone: ( )	Extension:

Fax: ( )

E-Mail:

5.	Project Site Address:

Street Address:

City/Town:

NINE-Digit ZIP Code [mandatory]

Municipality:

County(ies) of operation:

Check if multiple counties or statewide:

6.	Indicate the total reimbursement you will request during the following periods. Please ensure that the numbers in Question 19 add up to the requested grant amount:	$

Actual	Estimated

7.	Identify the project duration, including start date, end date, and total time in weeks or months.
Start Date: Click here to enter a date.	End Date: Click here to enter a date.	Total Time:

Please note: Project period begins upon grant award and must end by 9/30/2017, unless an extension is granted by DEP.

8.	Project Type (Choose the one category best describing the project; see instructions for detailed Project Type descriptions.)

Purchase and installation of EPA or CARB certified/verified exhaust controls

Purchase and installation of EPA or CARB certified/verified engine upgrade

Purchase and installation of EPA or CARB certified/verified idle reduction technology – Must be in combination with verified exhaust controls except for locomotive, marine shore power, truck stop electrification and school bus (MY2006 and newer) projects.

Purchase and installation of EPA or CARB certified/verified aerodynamic technologies and low rolling resistance tires – Must be in combination with verified exhaust controls.

Certified diesel vehicle or equipment engine repower, including clean alternative fuel repowers

Diesel vehicle or equipment replacement, including clean alternative fuel replacements

Clean alternative fuel conversions

9.	Please provide the name of the DEP staff person with whom you discussed your application, if any:

10.	Are facilities or infrastructure developments or improvements needed for this project?	Yes	No

If yes, is your project consistent with a county, municipal or multi-municipal comprehensive plan or zoning ordinance? Yes	No

11.	Has this proposal been submitted to another source for funding? Yes	No

Name of other source and anticipated award date:

12.	Is the project located on a:

brownfield (a vacant, previously utilized site)? Yes	No

designated Environmental Justice site?	Yes	No

13.	Is the project located in a priority area, as defined in the application instructions?

Yes	No	If yes, identify the county(ies):

14.	Is the project located in a ‘high-pollution area,’ as defined in the application instructions?

If yes, select the type of ‘high-pollution area’ from the choices below:

Port	Rail yard	Terminal	Distribution center

Truck Stop	Construction site	School bus yards/depot

Additionally, include a description of the location in the project description.

15.	Has the applicant identified any Small Diverse Businesses, which includes minority, women, veteran, and service-disabled veteran business enterprises, that may be used to supply goods or services for the proposed project?

Yes	No

If yes, identify the business and indicate if the business was found in the PA Department of General Services (DGS) database or the federal vendor database. See application instructions for details on the databases.

Business Name(s):

DGS	Federal Vendor Database

16.	How many vehicles or pieces of equipment are proposed for this project?

17.	Use the U.S. EPA’s Diesel Emission Quantifier (DEQ) to quantify emission reduction estimates for this project. See the application instructions for more information on using the DEQ. If your project emission reductions cannot be estimated using the DEQ, contact the Department to receive approval for an alternate calculation method.

Annual Emission Summary	NOX	PM2.5	HC	CO	CO2
Baseline of Vehicles Retrofitted/Modified (tons/year)
Percent Reduced (%)
Amount Reduced Per Year *(tons/year)
Amount Reduced Per Year *(lbs/year)

Select one: DEQ Emissions	Alternative Calculation Emissions

18.	Estimate the economic and energy savings that will result from the project.

(Insert more rows if necessary)	Quantity
Liquid Fuel Saved	gals/yr
Fuel Cost Savings	$ ($/yr)
Value of Goods and Services from Pennsylvania Companies	$ ($ over entire project)

19.	Complete the budget summary and detailed budget worksheet. Total for all categories (without matching funds) should equal the total project grant request in Question 6.

Budget Summary (Must be consistent with the Detailed Budget Tables):

CATEGORY	GRANT REQUEST (FROM DEP)	+	MATCH (FROM APPLICANT)	=	PROJECT COST (TOTAL)
Personnel	$	+	$	=	$
Contractual	$	+	$	=	$
Equipment	$	+	$	=	$
Supplies	$	+	$	=	$
Total for each column:	$	+	$	=	$

Detailed Budget Tables

PERSONNEL

TASK	PERSONNEL	HOURLY RATE	HOURS	BENEFITS	TOTAL COST
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
TOTAL PERSONNEL SALARIES AND BENEFITS	$

CONTRACTUAL

1.	CONTRACTOR SALARIES (List billing rate by task. Salary ranges are not acceptable; see application instructions for fitting expenditures within budget categories.)

TASK	CONTRACTOR	HOURLY RATE	HOURS	BENEFITS	TOTAL COST
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
$	$	$
TOTAL CONTRACTUAL SALARIES AND BENEFITS	$

2.	OTHER CONTRACTUAL EXPENSES

ITEM - Other (List specific item)	COST
$
$
$
$
$
TOTAL OTHER CONTRACTUAL EXPENSES	$

3.	TOTAL CONTRACTUAL (=1+2)

CONTRACTOR SALARIES AND BENEFITS	OTHER CONTRACTUAL EXPENSES	TOTAL CONTRACTUAL EXPENSES
$	$	$

EQUIPMENT (Construction-Related Costs)

ITEM	QUANTITY	COST PER ITEM	TOTAL COST
$	$
$	$
$	$
$	$
$	$
TOTAL EQUIPMENT	$

SUPPLIES (Non-Construction-Related Costs)

ITEM	QUANTITY	COST PER ITEM	TOTAL COST
$	$
$	$
$	$
$	$
$	$
TOTAL SUPPLIES	$

MATCH

Please use the following table to calculate matching contributions of cash, goods and services to be entered on the application form. All items listed must be accompanied by a letter of commitment.

CONTRIBUTOR	BUDGET CATEGORY	DESCRIPTION	STATUS	VALUE (in $)
$
$
$
$

20.A.	Executive Summary

20. B. Attachments

Attachment A: Business Plan

Attachment B: Detailed Project Description and Work Plan with Schedule

Attachment C: Environmental, Energy, and Economic Benefits

Attachment E: Vehicle/Equipment Description Reporting Form (Microsoft Excel format)

Attachment F: Supporting Documentation