North Carolina Division of Air Quality

North Carolina Division of Air Quality

2016 Diesel Emissions Reduction Grant

On-Road Mobile Project Form

Use this form for any on-road mobile projects. (e.g. truck replacement project)

Project Title
Project Coordinator
Organization Name
Organization Type / / Private Sector / / City/CountyGovt. / / State Govt.
/ Non-Profit / / Individual / / Other(explain):
Mailing Address
City / County / Zip
Telephone / Fax
E-mail
Alternate Contact Name
Alt. Contact Telephone / Alt. Contact E-mail
Total Amount Requested ($)
Matching Funds in Cash / In-Kind Matching (optional)
Project Summary:
Signature of Authorized Representative / Date
Signature certifies that this application is, to the best of your knowledge, truthful. Unsigned applications will not be accepted.

1Introduction and Project Description

1aBriefly describe your organization and the staff who will be working on the project

1bClearly describe yourproject plans, if awarded

1cAddress any “PROJECT SELECTION CRITERIA”from the 2016 Diesel Emissions Reduction Grant-Request for Proposal ( that may not be adequately addressed elsewhere

2Quantifiable Reductions

For truck replacement(s), please complete one table for each vehicle in your proposal. Make as many copies of this page as needed.

Number of vehicles in the project
This is vehicle 1 of __ vehicles in the project
Target Fleet,i.e., City/County vehicle, emergency, long haul or short haul truck, refuse hauler, street sweeper, school bus, etc.
Vehicle Class / Class 5 (16,001-19,500 lbs)
Class 6 (19,501-26,000 lbs)
Class 7 (26,001-33,000 lbs)
Class 8 (33,001 lbs and over)
School bus
Other (explain):
Before / After
Engine Make
Engine Model
Engine Family (see serial number plate on engine)
Engine Model Year
Fuel Type,i.e., diesel,
Biodiesel: B15, B20,etc.
Amount of fuel used per year
Annual miles per vehicle
Idling hours per year

2aDescribe the new equipment

The new equipment should be similar in horsepower and useof the old equipment.

• Is the equipment new or remanufactured old equipment?
• Is vehicle a hybrid or special use truck? Explain.

3Unquantifiable benefits

Describe any unquantifiable benefits in this section or other reasons besides emissions reduction why this project should be selected for funding.

4Budget______

Provide an itemized listing of all the project costs, including total amount of funds requested, and anyadditional sources of funds both from the applicant and other sources.

Budget Table

Item / Project Costs / Grant Funds / Your Organization / Other (Specify)
Total

5Permanence of Benefits

State the full lifetime of the project equipment. Also, state the remaining project equipment lifetime at the time the project occurs.

How long does this equipment typically last when new? / Years
When was the last engine rebuild on the old equipment?
How frequently do you rebuild the engine?
How much of the equipment life will be left in the old engine (minimum 3 yrs. required)? / Years

6Project Timetable or Schedule

All projects must be completed by September 30, 2017. Provide a step by step estimate of how long it will take to complete your project. Due to variable contract processing time, make the schedule relative to your contract start date rather than hard dates. For example, 1 month after the contract is in place – order for school bus retrofits will be made.

Task / Time
Contract Begins / July 2017
Contract ends –
Project Completed / September 30, 2017

6aSeasonal Concerns

Please indicate with a “yes” or a “no”, in the table below, the months in which the work on this project can possibly take place. For example, some equipment cannot be taken out of service during the summer months because it is steadily being used.

January / February / March / April / May / June
July / August / September / October / November / December

7Assurances

By signing below, the grantee assures that any equipment purchased with this grant will remain in North Carolina for 70% of the time for the next 3 years.

Good Faith Commitment of Location of Equipment Activity
As an authorized official of ______(organization name), I attest that, to the best of my knowledge, the information in this application is correct and at least 70% of the equipment's operation will occur in North Carolina for the next 3 years.
Signature / Date
Printed/Typed Name / Title

8Attachments

• Emissions Certificate/Letter for replacements, repowers, or conversions will be asked for if selected

• Letters of intent from contributors of matching funds or in-kind contributions (if applicable)

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