ATTACHMENT 1
OPERATION AND MAINTENANCE SUPPORT GRANT APPLICATION FORM
This document constitutes the application for an Operation and Maintenance (O&M) Support Grant. The Applicant shall complete an O&M Support Grant Application Form for each, individual hydrogen refueling station seeking O&M funding support.
Applicant’s Legal Name / Federal ID Number-
Station Owner’s Legal Name / Federal ID Number
-
Station Operational Date (actual or expected)
O&M Coverage End Date
/
/
Amount of Funds Requested for this Station / $
Address of the Proposed Hydrogen Fueling Station
O&M Cost Description (brief paragraph)
(for example, equipment maintenance $XX/month, insurance $XX/month, rent or lease $XX/month, utility costs XX% of the bill $XX/month, labor additional XX% $XX/month)
Applicant’s Project Manager (serves as point of contact for all communications)
Name:
Address:
City, State, Zip:
Phone:
E-Mail:
Applicant Is
Private Entity (including non-profits)
CA State Agency (including UC and CSU)
Government Entity (i.e. city, county, federal government, air/water/school district, joint power authorities, university from another state)
Will the Applicant procure subcontractors for this project? / No / Yes
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Certifications:
I hereby authorize the California Energy Commission to make any inquiries necessary to verify the information presented in this Application.
I hereby certify that this application does not contain any confidential or proprietary information. I further authorize the Energy Commission to distribute, publish, and use all the materials contained in this Application without limitation.
I hereby certify to the best of my knowledge and belief that I have read, understand, and do hereby accept the terms and conditions contained in this solicitation package, including the provisions of the Agreement Terms and Conditions. Further, I am willing to enter into an agreement with the Energy Commission to conduct the proposed project according to the terms and conditions without negotiation.
The Applicant agrees to the Scope of Work contained in Attachment 2 without modification. While modifications to the Scope of Work are not anticipated, the Energy Commission reserves the right to modify the Scope of Work if necessary.
I hereby certify to the best of my knowledge that the information contained in this Application is correct and complete.
Signature of Principal Investigator/Project Manager / Date:
Signature of Authorized Representative / Date:
Alternative and Renewable Fuel Attachment 1 GFO-17-601
and Vehicle Technology Program Page 1 of 1 L-D Vehicle Hydrogen
Refueling Infrastructure
Operation and Maintenance Support Grants