2024-chdv-grants-tcd-utility-part-template-2024-04.pdf

EPA Form Number: 5900-685

Burden Statement for EPA Form 5900-685: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0754). Responses to this collection of information are voluntary (2 CFR 200 at 2 CFR 1500). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental

Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

TCD Utility Partnership Template

Instructions: Planning early for long-term electric charging infrastructure needs is important for project success. This form was created for the convenience of applicants and utility providers to assist in discussing the potential new zero-emission vehicle/equipment project and infrastructure projects, including key components such as anticipated costs and timelines.

The intent of this form is to ensure awareness of all parties involved in the potential new zero-emission vehicle project. This document is not binding, meaning that applicants and utility providers do not need to complete a full utility analysis or otherwise fully commit to proceeding with the potential new zero emissions vehicle/equipment project as outlined on this form.

The information identified in this worksheet may be used to support the Project Narrative component of the grant application package, but it is not required. Applicants may include a copy of this worksheet for each project location included in the application.

Regardless of whether applicants use this worksheet, the EPA strongly encourages applicants to coordinate with their and electric utility providers to determine anticipated costs and timelines.

Additionally, applicants should keep fleet electrification expansion plans in mind, as futureproofing for upcoming needs can ultimately decrease overall utility upgrade costs.

OMB Control Number: 2060-0754 Expiration Date: 04/30/2027

Office of Transportation and Air Quality April 2024

Requested in Application [Please provide the number of mobile source equipment (by type) and chargers requested in your application.]

Current Electric Fleet at time of Application

Submission [Please provide the number of vehicles and chargers already in your electric fleet.]

Type and Number of Electric

Vehicles/Equipment:

Number of DC Fast Charger

Units:

Number of Level 2 AC

Charger Unites:

Number of Other EV

Charger Units:

(please specify the type of chargers)

Number of Shore Power

Pedestals:

Number of Units of Other

Eligible Charging and/or

Fueling Infrastructure:

(please specify the type of infrastructure)

Expected location(s) (street, city, state) of Charger and/or

Electrical Infrastructure

Installations:

1. Fleet Information

The EPA recommends that applicants fill out information for each individual utility provider they are communicating with about their potential electric infrastructure project. The EPA recommends that applicants communicating with more than one utility identify whether the project scope occurring with a specific utility provider would constitute all or only part of the potential electric infrastructure project.

a. Utility Provider #1

Name of the Utility Provider:

Utility Contact Name:

Utility Contact Phone:

Utility Contact Email:

b. Utility Provider #2

Name of the Utility Provider:

Utility Contact Name:

Utility Contact Phone:

Utility Contact Email:

c. Utility Provider #3

Name of the Utility Provider:

Utility Contact Name:

Utility Contact Phone:

Utility Contact Email:

d. Utility Provider #4

Name of the Utility Provider:

Utility Contact Name:

Utility Contact Phone:

Utility Contact Email:

2. Utility Information

3. Applicant and Utility Coordination Affirmation

By signing this Affirmation, I certify that I am an Authorized Representative for the Applicant or

Utility Provider identified below.

If an applicant has not received a response from their local utility provider(s) after repeated attempts to discuss this form, then they may submit the document with signatures from all parties involved in the application except for the utility, with the understanding that there will be continued outreach with the utility after the application deadline. During application review, the EPA may reach out to request an updated copy of this form that includes all required signatures. The EPA expects all the appropriate signatures to be present at the time of award, and omission of these signatures may compromise an applicant’s selection status.

• For applicants to the Clean Heavy-Duty Vehicle Program: In the event the applicant attempted to contact the utility provider about this form, but received no response, the applicant should also email cleanhdvehicles@epa.gov with the following information: name of the utility, name of utility point of contact they’ve been working with,(or attempting to work with), and information on when the applicant attempted to contact the utility provider.

Applicant Affirmation

I have discussed the project plan for the fleet and charging infrastructure outlined above with the

Utility Company, and if applicable with the School District and/or Port Authority, and others as appropriate.

Applicant Organization Name Authorized Representative (Signature) Date

Utility Provider Affirmation

I have discussed the project plan for the fleet and charging infrastructure outlined above with the

Applicant listed above, and if applicable, the third parties below, including the relevant School

District and/or Port Authority, and others as appropriate.

Utility Provider #1 Name Authorized Representative (Signature) Date

Utility Provider #2 Name Authorized Representative (Signature) Date

Utility Provider #3 Name Authorized Representative (Signature) Date

Utility Provider #4 Name Authorized Representative (Signature) Date mailto:cleanhdvehicles@epa.gov

I have discussed the project plan for the fleet and charging infrastructure outlined above with the

Utility Company and Applicant Organization, listed above, and others as appropriate.

Entity Organization Name Authorized Representative (Signature) Date

OthOtheerr Entity Afy Affirfirmmatiationon

(applicable only if part of project; e.g., school district, other state or local agencies, including

Port Authorities)

This section is NOT required to be completed and/or submitted to the EPA, however, the EPA strongly encourages applicants and utility providers to discuss the items listed in Section 4. Additionally, applicants should keep fleet electrification expansion plans in mind, as futureproofing for upcoming needs can ultimately decrease overall utility upgrade costs.

Please work with your utility to provide a rough estimate of the total engineering and construction cost for utility owned infrastructure

(in front of the meter) for the project based on the number of vehicles and eligible charging and/or fueling infrastructure listed in the applicant’s application:

In the box below, please briefly describe the scope of any needed utility upgrades for the project. Please consider whether engineering, construction, and/or permitting is needed, whether an interconnection study is necessary, and the extent of services needed for completion. This should include whether upgrades are necessary for the following pieces of equipment:

• Power transformer

• Terminator Pole

• Service lateral/conductor

• Metering

• Primary line extension

• Any additional equipment

Based on the information provided above, please provide an estimate of time required to complete the necessary utility-owned infrastructure (in front of the meter) upgrades:

4. OPTIONAL: Planning for Utility Upgrades