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Marine Vessel Application FormPeninsula Diesel Application FormApplicant InformationFirst Name*Last Name*Email*Phone*WebsiteBusiness or Organization Name*Business or Organization Phone Number*Business or Organization Address*City*StatePlease selectALAKARAZCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPostal Code*CountryPlease selectAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatia (Hrvatska)CubaCyprusCzech RepublicCongo (DRC)DenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Islas Malvinas)Faroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong Kong SARHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SARMacedonia, Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe Primary Contact Information(Who oversees equipment use and can report meter reading usage to District.)First Name*Last Name*Phone*Email* Marine VesselMarine Vessel NameMake*Model*Model Year*Vessel Type________________________Subject to Commercial Harbor Craft RegulationSchedules for Meeting Tier 2 or Tier 3 StandardsCheck one or more boxes which apply*BargeCrew and SupplyExcursionFerryTowboatTugboatNOT Subject to Commercial Harbor Craft RegulationSchedules for Meeting Tier 2 or Tier 3 StandardsCheck one or more boxes which apply*FishingPilotWorkboatWhich 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 EngineUse extra fields for additional engines if necessaryFuel 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* Upload% Completed0Serial Plate* Upload% Completed0________________________Additional EngineFuel TypeMakeModelModel YearSerial NumberHorsepowerDisplacement (Liters)Number of CylindersEPA Family Number or ARB Executive Order NumberEPA Tier RatingEngine Photo Upload% Completed0Serial Plate Upload% Completed0 Replacement EngineReplacement Engine NotesNew 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 EngineDealer NameFuel TypeMakeModelModel YearHorsepowerDisplacement (Liters)Total Project CostPrice Quote for Replacement Engine Engine Usage InformationPercent of Vessel Activity in CA Coastal Waters*Propulsion 1Engine Serial Number*Hour Meter Reading*Date of Reading*Percentage of Total Fuel Consumed by Engine*________________________Propulsion 2Engine Serial NumberHour Meter ReadingDate of ReadingPercentage of Total Fuel Consumed by Engine________________________Auxiliary 1Engine Serial NumberHour Meter ReadingDate of ReadingPercentage of Total Fuel Consumed by Engine________________________Auxiliary 2Engine Serial NumberHour Meter ReadingDate of ReadingPercentage of Total Fuel Consumed by Engine________________________OtherEngine Serial NumberHour Meter ReadingDate of ReadingPercentage of Total Fuel Consumed by Engine________________________OtherEngine Serial NumberHour Meter ReadingDate of ReadingPercentage of Total Fuel Consumed by Engine Disclosure StatementHave You Applied for or Received Incentive Funding?*YesNoIf Yes, complete the following information:Entity Applied toDate and Number of ApplicationFunding (or Potential Funding) AmountStatus of FundingAdditional InformationList 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 metWARNINGAn 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 StatementAs 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 regulationsFull 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 ReportAttach a copy of your Commercial Harbor Craft Initial Report filed with California Air Resources Board (ARB). Upload% Completed0The 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 & SubmissionI 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 PreparerDateAmount Received to Prepare ApplicationSource of PaymentBy checking the box above, I certify under penalty of perjury all information is true and correct to the best of my knowledgeHeading Submit12345678910
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