Department of Administration
Division of Energy, Housing & Community Resources
DOA-9563 (R05/2016) / / Return Completed Form To:
WI Department of Administration
Attn: WI Diesel Truck Idling Reduction Grant Program
101 E. Wilson St., P.O. Box 7970
Madison, WI 53707-7970
Exhibit C2 Diesel Truck Idling Reduction Grant Program 6-Month Report
6-month report - FLEET & TRUCK INFORMATION (A copy of an engine download is NOT required with the submittal of this report.)
Contract Number: / Grant Recipients are required to answer every question.
Business Name or Owner Operator Name: / Start Date: / End Date:
Long Haul Truck Tractor(s): / Truck 1 / Truck 2 / Truck 3 / Truck 4
1 / Vehicle Identification Number
2 / Unit Number (if applicable): / N/A / N/A / N/A / N/A
3 / Truck Make:
4 / Truck Model:
5 / Sleeper Berth Truck Tractor (y/n): / Yes / No / Yes / No / Yes / No / Yes / No
6 / Engine Model Year? If 2008, was the truck manufactured after January, 2008 (y/n). / Yor N / Yor N / Yor N / Yor N
7 / Engine Rebuilt (y/n)? If yes, what year was the engine rebuilt? / Yor N / Yor N / Yor N / Yor N
Using six months from the date the idle reduction unit was installed, answer the following:
8 / Total Miles Traveled:
9 / Total Miles Traveled in Wisconsin:
10 / Estimate the Total Miles Traveled in Wisconsin Non-attainment1 Counties:
11 / Average Miles Per Gallon:
12 / Average Idling Time (hours/month):
13 / Idle Percentage Time (%): / % / % / % / %
14 / Estimate the Average Idling Time in Wisconsin Non-attainment1 Counties (hours/month):
15 / Fuel Consumed (gallons):
Approximately what percentage (%) has the truck traveled in the following areas: (Please use whole numbers only.)
16a / Midwest2 / % / % / % / %
16b / Northeast2 / % / % / % / %
16c / South2 / % / % / % / %
16d / West2 / % / % / % / %
DOA-9563 continued
17 / Type: Auxiliary Power Unit (APU), Battery Powered HVAC Unit (BP HVAC), Direct Fired Heater/Bunk Heater (DFH), Energy Recovery System (ERS), Other (please specify)
18 / Manufacturer of the Idling Reduction Unit:
19 / Model:
20. Feedback by driver(s) (if any):
21. Maintenance performed on truck tractor(s):
22. Any problems or concerns with the idle reduction units (e.g. maintenance):
I certify that the information within this report is correct and was derived from on-board, electronically recorded data:
Signature / Date
Facility Contact / Title
*Wisconsin Ozone Nonattainment Counties include: Kenosha, Racine, Milwaukee, Waukesha, Washington, Sheboygan, Ozaukee, Manitowoc, Kewaunee, and Door
1Midwest: Indiana, Illinois, Iowa, Kansas, Michigan, Nebraska, Minnesota, Missouri, North Dakota, Ohio, South Dakota, Wisconsin
1Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
1West: Arizona, California, Colorado, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, Washington, Wyoming
1South: Alabama, Arkansas, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, S. Carolina, Tennessee, Texas, Virginia, W. Virginia
Geographical map is from the U.S. Census: http://www.census.gov/geo/www/us_regdiv.pdf
Retain a copy of the completed form for your records and fax (608/267-6931), email () or mail to:
Wisconsin Department of Administration, Diesel Truck Idling Reduction Grant Program, DECHR 6th Floor,
PO Box 7970 Madison, WI 53707-7970. Or for additional copies go to http://www.stateenergyoffice.wi.gov/DieselGrantProgram
Questions filling out this report? Contact Jean Beckwith at or 608/261-2517
This form can be made available in alternate formats to individuals with disabilities upon request.