Green Chemistry and Design - Form

/ Green Chemistry and Design
2011 Grant Application
Doc Type: Grant Application

Instructions on Page 3

Please read the complete Request for Proposals (RFP) and other associated documents before submitting this application.

Part I Application Cover Page

Applicant name:
Address:
City: / State: / Zip code: / County:
Mailing address (if different):
City: / State: / Zip code:
Contact name: / Title:
Authorized Representative (if different than Contact):
Title:
E-mail: / Applicant’s website:
Phone: / Fax: / MN House Dist:
State Tax ID: / Federal Tax ID:
Project title:
Project summary:
Grant requested: / $ / + Matching funds/value of in-kind: / $ / = Total project cost: / $

Part 2 Project Description

2a. / Project purpose(s):
2b. / 1. / Anticipated environmental outcomes/benefits:
2b. / 2. / Likelihood of achieving projected outcomes/benefits:
2c. / Procedures to measure success of project:
2d. / How Green Chemistry and Green Engineering principles are considered or incorporated:
2e. / Types of technologies and methods:
2f. / Degree of dissemination of project results:

Part 3 Experience and Qualifications

3a. / Applicant’s and team member’s success at innovation or improvement:
3b. / Applicant’s environmental compliance and enforcement history:
3c. / Applicant’s and team member’s pertinent qualifications and experience:
3d. / Demonstration of team members’ commitment:

Part 4 Project Work Plan and Budget

4a. / Project work plan:
1. / Project purpose(s):

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats

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4b. Gantt chart:

(Insert Gantt chart here)

4c. Budget: Use attached budget table:

(Insert budget table here)

Certification

In signing this application the applicant certifies:

1.  To the best of their knowledge, the information being submitted is true and correct.

2.  The applicant is located in, doing business in, incorporated in, or with primary legal residence in Minnesota.

3.  The applicant will accept the terms and conditions in the grant contract, unless otherwise noted via a separate letter. (Please note that any exceptions to the proposed Terms and Conditions as provided in the Sample Grant Contract should be addressed in a separate letter and signed by the Authorized Representative.)

I am a legally authorized signatory or designee for the submittal of this information, and any other required information on the behalf of the participant.

Authorized representative signature:

Print name: / Title:
Signature: / Date:

Note: Application must be scanned and e-mailed for submittal.

Instructions for Completing Application (may be deleted before submitting)

Part I Application Cover Page

·  MN House District: Applicant’s district can be found on the Web at http://www.gis.leg.mn/mapserver/districts

·  Project Title: Choose a title that is short, yet descriptive of the type of project being proposed.

·  Project Summary: Give a concise summary of the proposed project; include what, why, and expected results.

·  Respond to all questions. Expand as necessary.

·  Matching Funds/Value of In-Kind:

For every two grant dollars requested, the applicant must provide a one dollar match. The match may be in the form of in-kind services or cash, but cannot be funds derived from other funding sources provided by or administered by the Federal Government, Minnesota Pollution Control Agency (MCPA) or other state agencies or departments. A reasonable dollar amount must be assigned for all matching in-kind contributions.

Part 2 Project Description

Provide a complete response that addresses the following items:

2a) Clearly state the purpose(s) of this project.

2b) Clearly state the anticipated environmental outcomes/benefits associated with this project and the likelihood of achieving them.

Present detailed forecasts of specific improvements in life-cycle environmental and energy impacts and/or commitments to collecting data for metrics for such impacts, considering but not limited to:

1.  Direct chemicals-of-concern* replaced (mass or volume)

2.  Direct production waste avoided (mass or volume)

3.  Direct production energy consumption reduced

4.  Indirect upstream effects

·  chemicals-of-concern* replaced (mass or volume)

·  production waste avoided (mass or volume)

·  production energy consumption reduced

5.  Indirect downstream effects

·  chemicals-of-concern* replaced (mass or volume)

·  production waste avoided (mass or volume)

·  production energy consumption reduced

6.  Other life-cycle impact reduction metrics as measurable by the proposer.

* U.S. EPA’s National Partnership for Environmental Priorities chemicals; U.S. EPA’s Chemicals Action Plans; Minnesota Chemicals of High Concern

2c) Clearly describe what procedures (criteria, methods, and controls) will be used to identify, record, and compile pertinent information to measure and evaluate the success of the project.

2d) Clearly describe how the 12 principles of Green Chemistry and 12 principles of Green Engineering were considered, and where applicable, incorporated or set aside as infeasible or inapplicable.

2e) Clearly describe what, if any, innovative technologies and/or methods are being proposed in this project.

2f) Clearly state the potential for future dissemination of project results.

Part 3 Experience and Qualifications

Provide a complete response that addresses the following items:

3a) Applicant’s and team members’ culture of or success at innovation or improvement

3b) Applicant’s environmental compliance and enforcement history for last 2 years

3c) Applicant’s and team members’ experience and qualifications related to implementing and completing this type of project.

3d) Team members’ commitment, which can be demonstrated by statements or descriptions of management support, robust project staffing, and the business plan for product development and launch.

Part 4 Project Work Plan and Budget

Provide a complete response that addresses the following items:

4a) Project Work Plan: use the following format for your project work plan. If awarded a grant, the reporting requirements for your project will follow this same format.

Objectives/Tasks – Outline the key steps (objectives) to implement the project and the necessary actions (tasks) to implement each step.

There is no minimum or maximum number of objectives/tasks a project could have in the Work Plan.

Blank Example of format to use for Objectives/Tasks

Objective :

Task :

Task :

Example

Objective 5 of 6 – Reporting

Task 5A: Will submit Semi-Annual Report(s) as applicable.

Task 5B: Will submit a Final Report.

4b) Gantt Chart – Provide a timeline of proposed project using a Gantt Chart format.

Example

2011 / 2012
Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Jan / Feb / Mar
Execute subcontracts with technical partners.
Review and select alternative product or pathway to alternative.
Application research and testing.
Production and operations design – resource and regulatory needs analysis.
Business plan and projections.
Environmental benchmarking and projected performance of new design or redesign.
Semi-annual report
Production adjustments
Operate and establish new product environmental parameters
Monitor and collect data.
Evaluate findings
Final report

4c) Budget – Create a detailed Budget in the format provided for each objective and the task(s) that link to it as identified in your project’s Work Plan. Objectives and tasks should be stated exactly as they are in their work plan. Identify the person responsible and their company and title. Subcontracted consultants can be indicated as such.

Sample Budget-for an objective and its related tasks

I. / II. / III. / IV.
Cost Category / Unit Cost / Quantity / Grant Funds / Match
Cash / Match
In-kind / Total
Budget
Objective 3 Of 6: Data Collection
Task 3A) Determine data measurement methods
ABC Co. / Project Manager, John Doe / 32.69 / $/hr / 50.00 / hrs / 1634.50 / 1634.50
ABC Co. / Research and Development staff, Jane Doe / 28.35 / $/hr / 20.00 / hrs / 567.00 / 567.00
ABC Co. / Information Technology staff, Joe Doe / 22.18 / $/hr / 5.00 / hrs / 110.90 / 110.90
Subcontracted Consultant / 110.00 / $/hr / 20.00 / hrs / 2200.00 / 2200.00
Subtotal / 2200.00 / 0.00 / 2312.40 / 4512.40
Task 3B) Monitor and Collect data
ABC Co. / Project Manager, John Doe / 32.69 / $/hr / 10.00 / hrs / 326.90 / 326.90
ABC Co. / Production Manager, Laura Doe / 26.50 / $/hr / 20.00 / hrs / 530.00 / 530.00
ABC Co. / Production staff, Lynn Doe / 20.00 / $/hr / 75.00 / hrs / 1500.00 / 1500.00
Subcontracted Consultant / 110 / $/hr / 10.00 / hrs / 1100.00 / 1100.00
Subtotal / 1100.00 / 0.00 / 2356.90 / 3456.90
Task 3C) Analyze data
ABC Co. / Project Manager, John Doe / 32.69 / $/hr / 30 / hrs / 980.70 / 980.70
ABC Co. / Production Manager, Laura Doe / 26.50 / $/hr / 20 / hrs / 530.00 / 530.00
Subcontracted Consultant / 110 / $/hr / 80 / hrs / 8800.00 / 8800.00
Subtotal / 8800.00 / 0.00 / 1510.70 / 10310.70
Objective 1 - Total / $12,100.00 / 0.00 / $6,180.00 / $18,280.00

www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats

p-p2s10-04-1 • 12/22/10 Page 5 of 5