State of Wisconsin Wisconsin Clean Diesel Grant Program

Department of Natural Resources Price Quote

dnr.wi.gov Form 4500-179 (09/12) Page 1 of 1

Notice: Complete this form to apply for Diesel Emission Reduction Act (DERA) grant funds administered by WDNR that were received from the U.S. EPA. Incomplete forms may not be considered. Personally identifiable information collected will be used for grant administration and may be provided to requesters as required by Wisconsin’s Open Records law (ss. 19.31-19.39, Wis. Stats.).

TO BE FILLED OUT BY THE EQUIPMENT VENDOR

Technology Vendor Information:

Company Name: Phone #:

Address: City: State: Zip:

Customer/Applicant:

Business Name: Contact Name:

Equipment Information & Price Quote: (Make copies of this form if needed for additional equipment)

When obtaining price quotes, please be mindful that grant awards are limited to a total of $50,000. Grant requests should not exceed this amount, after subtracting all required and voluntary match dollars.

Proof of United States Enviromental Protection Agency (EPA) or California Air Resources Board (CARB) verification is required for each type of retrofit device being quoted. An EPA or CARB engine emission certificate of conformity is required for any engine repower and equipment replacement project being quoted. Verification statement(s) and/or engine certificates of conformity must be attached to this price quote.

VIN¹ / Technology ² / Technology Make / Model / Base Unit Price³ / Installation
Price4 / Total Price5
Total Project Cost6

(1)  For replacement projects, list the VIN of the equipment to be replaced, not the new equipment.

(2)  List the type of technology to be installed on that specific piece of equipment (e.g. DOC, replacement, direct fired heater, etc.).

(3)  Base Unit Price is the cost of the technology with all hardware required for proper installation (excludes optional accessories).

(4)  Put “NA” if there is no installation cost or if the customer is self installing. Costs of self installations are not eligible.

(5)  Total Price includes base price, installation labor if by vendor, and taxes (if applicable). Costs for optional accessories, and all other costs are ineligible and any core charges should be excluded from this quote.

(6)  Total Project Cost is the sum of the amounts in the “Total Price” column.

Price quote prepared by:

Signature / Date
Print Name / Title
Phone Number / Email Address