Marine Vessel Application - Peninsula Diesel

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Marine Vessel Application Form

Peninsula Diesel Application Form

Applicant Information

First Name*

Last Name*

Email*

Phone*

Website

Business or Organization Name*

Business or Organization Phone Number*

Business or Organization Address*

City*

State

Postal Code*

Country

Primary Contact Information

(Who oversees equipment use and can report meter reading usage to District.)

First Name*

Last Name*

Phone*

Email*

Marine Vessel

Marine Vessel Name

Make*

Model*

Model Year*

Vessel Type

________________________

Subject to Commercial Harbor Craft Regulation

Schedules for Meeting Tier 2 or Tier 3 Standards

Check one or more boxes which apply*

Barge

Crew and Supply

Excursion

Ferry

Towboat

Tugboat

NOT Subject to Commercial Harbor Craft Regulation

Schedules for Meeting Tier 2 or Tier 3 Standards

Check one or more boxes which apply*

Fishing

Pilot

Workboat

Which Fishing Permits does this vessel currently have?*

U.S. Coast Guard Documentation Number*

Lloyds Register/IMO Ship ID Number*

California Dept. Fish & Game Number*

California Vessel Registration (CF) Number*

Wet or Dry Exhaust?*

Number of propulsion engines on vessel*

Number of propulsion engines to be repowered*

Number of auxiliary engines on vessel*

Number of auxiliary engines to be repowered*

Vessel berthing location*

Existing Engine

Use extra fields for additional engines if necessary

Fuel Type*

Make*

Model*

Model Year*

Serial Number*

Horsepower*

Displacement (Liters)*

Number of Cylinders*

EPA Family Number or ARB Executive Order Number*

EPA Tier Rating*

Engine Photo*

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Serial Plate*

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________________________

Additional Engine

Fuel Type

Make

Model

Model Year

Serial Number

Horsepower

Displacement (Liters)

Number of Cylinders

EPA Family Number or ARB Executive Order Number

EPA Tier Rating

Engine Photo

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Serial Plate

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Replacement Engine

Replacement Engine Notes

New engine must conform to Commercial Harbor Craft Regulation requirements for replacement engines. Engines participating in the averaging, banking, and trading (ABT) program that are certified to family emission limits (FEL) higher than the applicable emission standards, as designated on the Executive Order, are ineligible to participate in the CMP. The replacement engine must provide at least a 15% NOx reduction relative to the baseline engine.

Dealer Name*

Fuel Type*

Make*

Model*

Model Year*

Horsepower*

Displacement (Liters)*

Total Project Cost*

Price Quote for Replacement Engine*

________________________

Additional Replacement Engine

Dealer Name

Fuel Type

Make

Model

Model Year

Horsepower

Displacement (Liters)

Total Project Cost

Price Quote for Replacement Engine

Engine Usage Information

Percent of Vessel Activity in CA Coastal Waters*

Have You Applied for or Received Incentive Funding?*

Yes

If Yes, complete the following information:

Entity Applied to

Date and Number of Application

Funding (or Potential Funding) Amount

Status of Funding

Additional Information

List any other financial incentive received to co-fund this project, including tax credits or deductions, grants, or other public financial assistance for the same equipment/engine. There is no limit on the number of co-funding sources to fund a project as long as total project as long as total project costs are not exceeded and applicant cost share requirement is met

WARNING

An applicant who is found to have applied for or received incentive funds from another entity or program for the same project without disclosing that information as required by the 2017 Carl Moyer Program Guidelines, Chapter 3, L. Co-funding Moyer Program Projects with Other Funding Sources, shall at minimum be disqualified from funding for that project from all sources within the control of an air district or ARB. ARB and the air district may also seek civil penalties for such non-disclosure.

Regulatory Compliance Statement

As an applicant/participant of the Marine Repower Grant Program I certify that:

Business or Organization Name*

Is in compliance with and will remain in compliance with all federal, state, and local air quality rules and regulations

Full Name*

Date*

By checking the box above, I certify all information is true and correct to the best of my knowledge

Commercial Harbor Craft Initial Report

Attach a copy of your Commercial Harbor Craft Initial Report filed with California Air Resources Board (ARB).

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The initial report should include a copy of each page of the report including; Company Contact, Vessel Information Page, and Engine Information for each engine on the vessel

Agreement & Submission

I hereby certify under penalty of perjury that all information provided in this application and any attachments are accurate and true, and I am authorized to represent the person or company or public agency indicated below to sign for this application and all other contracts or agreements necessary to implement the project for which funding is hereby requested.

Person Who Filled Out Application*

Name of Responsible Party*

Date*

________________________

If this application was prepared by someone other than above:

Name of Preparer

Date

Amount Received to Prepare Application

Source of Payment

By checking the box above, I certify under penalty of perjury all information is true and correct to the best of my knowledge

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Peninsula Diesel Contact Form

First Name*

Last Name*

Email*

Phone*

Subject*

Message*

File Upload

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