ETHANOL INFRASTRUCTURE INCENTIVE PROGRAM

Storage Tank Program Application

SOUTH DAKOTA GOVERNOR’S OFFICE OF ECONOMIC DEVELOPMENT

Application deadlines are Dec. 31, 2016. You are encouraged to apply early to be considered for an award.

Please complete and submit this form with all required supporting documents.

1. Name of Station ______Duns #______Address______City______State ______Zip______Phone______Email______

2. Storage Tank Project Address: (if different than above)

Address: ______City ______State ______Zip______

3. Contact Person Name: ______

Affiliation with Applicant: ______Address______City______State ______Zip______Phone______Email______

4. By checking yes in this box, you certify that your site’s existing infrastructure and new infrastructure will comply with all South Dakota Department of Environment and Natural Resources rules and regulations. Yes No

NOTE: Further information on the Department of Environment and Natural Resources rules and regulations that may pertain to your project can be found at this site: http://denr.sd.gov/des/gw/tanks/PlansAndSpecifications.aspx

5. Project description: ______

6. Capacity of storage tank being installed: ______gallons

o  A qualified storage tank must:

§  Be rated for a minimum of 6,000 gallons volume of storage;

§  Help make ethanol products available for retail purchase by the general public;

§  Meet all current industry and compatibility standards with all applicable equipment;

§  Must become part of the fueling infrastructure capable of meeting the fueling requirement listed below.

§  Dispense a 10 percent blend of ethanol;

§  Dispense a 15 percent ethanol or more, and;

§  Dispense a blend of 25 percent ethanol or more.

7. Expected project beginning date ______

Expected project completion date ______

8. Name(s) of local area that will be served by the project (counties, cities, municipalities, etc.):

______

9. Describe the anticipated market for ethanol at the project site, including major roadways (Interstate systems) within the service territory: ______

10. How much fuel does the project station sell on an annual basis (in gallons)? ______

Gasoline and ethanol based products (excluding E85):______

E85: ______Diesel Base Products:______

11. By checking yes in this box, you certify that the new ethanol storage tank will meet or exceed UL 87A guidelines and comply with existing fueling guidelines? Yes No

12. Will the new storage tank replace a tank already in place?

Yes No

13. Will the new tank hold fuel other than an ethanol blended product?

Yes No

If yes, please explain: ______

14. By checking yes in this box, you certify you understand that after receiving a grant the retail location listed above will be required to sell mid-level ethanol blended fuels through at least December 30, 2021. Yes No

15. Provide a detailed cost estimate with this application that delineates the cost of the tank, the installation cost of the tank, and the costs of any other work items that are expected to be accomplished at the time the installation of the tank takes place.

Please note: Due to federal grant requirements, successful applicants will be required to provide semiannual site performance reports to the State through February 1, 2022. The site performance report form will be made a part of the applicant’s executed agreement with the State.

Certification:

I, the undersigned authorized representative of the applicant, certify that to the best of my knowledge the information in the application is true and correct, and, if funded, the applicant will carry out the project activities in the manner described in this application and sell mid-level ethanol blended fuels, at a minimum through December 30, 2021, at the retail location listed above. I also certify that the applicant shall maintain accounting records in accordance with generally accepted accounting principles and that the funds awarded will be included in those audits or financial statements that cover all or part of the project duration period noted above. I further certify that the applicant represents a gasoline retail station within the state of South Dakota, and is in compliance with all applicable Federal and State laws, regulations, Executive Orders, and other generally applicable requirements, which are incorporated into this agreement by reference, for constructing and operating motor fuel storage and dispensing equipment. I also further certify that the applicant is in good financial standing and has no delinquencies on existing South Dakota State Government grants or loans.

______

Signature Name (Please Print)

______

Title Date

Subscribed and sworn to

before me this ____ day

of ______, 20___.

______

Notary Public - South Dakota

(Seal)

My Commission expires

______, 20___.

Mail original or email a scanned copy of the original completed application and supporting documents to:

Paul Mehlhaff

South Dakota Governor’s Office of Economic Development

711 E. Wells Avenue

Pierre, South Dakota 57501

Email:

Website http://www.sdreadytowork.com/Financing-Incentives/Ethanol-Infrastructure-Incentive-Program.aspx
Department Use Only
Approved / Amount of Grant / Authorized Signature:
Denied / Date

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