Clean Fuel Advanced Technology LPG Proposal Application
Overview
Organization:
Project Coordinator:
Address:
City: County: Zip:
Telephone: FAX:
Email:
Alternate Contact Person/Telephone/Email:
Project location (if different than applicant location)
Address:
City: County: Zip:
Applicant type (check one): Public Private
Total Project Cost: $ Amount Requested: $
Matching Funds: $ (minimum 20% of total project cost)
Project type/specifics:
- Alternative Fuel or Advanced Technology Vehicles:
Vehicle type (make, model, year):
Dedicated Bi-fuel B
Number of vehicles:
Estimated per-vehicle annual mileage:
Estimated % miles driven in eligible counties
Estimated % miles using alternative fuel (bi-fuelapplications):
Average conventional fuel economy (MPG):
Alternative fuel station(s) where vehicle(s) will refuel (address):
- AFV Conversions and Up Fits:
Vehicle type (make, model, year) to be converted/ up-fitted:
Number of conversions or up fitsto be installed:
Dedicated Bi-fuel B
Estimated % miles using alternative fuel (bi-fuel applications)
Estimated per vehicle annual mileage:
Average conventional fuel economy (MPG):
Alternative fuel station(s) where vehicle(s) will refuel or recharge (address):
______
- Refueling Infrastructure:
Estimated annual gallons to be dispensed:
Open to the public: Yes No
Other Emission Reduction Efforts: How does this project fit with current or future emission reduction efforts?
Emission Reductions: total project annual grams per mile.
Check if attaching own data Leave below blank if NCSC is calculating.
CO:NOx: VOCs: PM:
“Buy America” Compliance
Applicant hereby certifiescompliance with “Buy America” requirements; OR
Applicant hereby certifies “Buy America” is inapplicable to this project.
(For AFV purchases) Applicant hereby certifies that vehicle final assembly occurs in the U.S.
Project Description
Statement of Work
Project Summary:
Task #1: Acquisition and Installation of Equipment or Infrastructure.
tASK 1 DELIVERABLES
Deliverable 1.1: Copies of paid invoices for all costs associated with project will be provided. If submitting more than one invoice for reimbursement, final invoice will be marked as such. If only submitting one invoice, thiswill be marked as final. Cost share letter will be submitted with final invoice [refer to deliverable 4.1].
Deliverable 1.2:Brief description of what was accomplished will be provided.
Task #2: Usage tracking of project technology/fuel.
tASK 2 DELIVERABLES
Deliverable 2.1: A minimum of 6 months of recordedusage will be provided in acceptable form.
Deliverable 2.2: An estimate of gallons usage or saved for additional months totaling 36 will be provided.
Task #3: Public Awareness and Education.
tASK 3 DELIVERABLES
Deliverable 3.1: Documentation of all Public Awareness and Education activities will be provided via quarterly report template provided by the NC Clean Energy Technology Center.
Deliverable 3.2: Copies of all press releases and promotional material used to showcase project to the public will accompany quarterly reports. All press releases will acknowledge support through the NC Clean Energy Technology Center at NC State University with federal Congestion Mitigation Air Quality funding provided from the NC Department of Transportation.
Deliverable 3.3: Photo of project signage and /or photo of vehicle decals will be provided.
Deliverable3.4: Documentation of participation in NC Smart Fleet initiative (if applicable)
Task #4: Reporting.
tASK 4 DELIVERABLES
Deliverable 4.1: Cost share documentation on letterhead will accompany final invoice.
Deliverable 4.2: Completion of quarterly progress reports
Deliverable 4.3 Copies of paid invoices for grant funded project [see Deliverable 1.1] will accompany all requests for reimbursement.
Deliverable 4.4: One (1) final report summarizing project deliverables.
Timeline
ProjectDates: April 30, 2015 – March 31, 2016
1stQuarter:*April 30, 2015 – June 30, 2015
Quarterly report due: July 15, 2015
2ndQuarter: July 01, 2015 – September 30,2015
Quarterly report due: October 15, 2015
3rdQuarter: October 01, 2015 – December 31, 2015
Quarterly report due: January 15, 2016
4rdQuarter: January 01, 2016 – March 31, 2016
Quarterly and final report due: April 15, 2016
*Indicates elongated or shortened quarters due to overall project period.
Budget
1