ESBD_361429_1717428534698_582-24-85807-RG-Rebate-Replace Repower App-FINAL-acc.pdf

Replacement and Repower Projects and Refueling Infrastructure Projects Application Form

Rebate Grants Program Texas Commission on Environmental Quality (TCEQ)

Texas Emissions Reduction Plan (TERP) Solicitation No. 582-24-85807-RG

Este documento es la Aplicación para Solicitud de Subvenciones para el Programa de Subvenciones de Reembolsos (Rebate por sus siglas en Inglés). La información en este documento lo ayudará a determinar si califica para una subvención. Comuníquese al 800-919-TERP (8377) para obtener ayuda con esta información.

Eligible Activities

This project application form should only be completed by applicants seeking to replace or repower on-road heavy-duty diesel vehicles or non-road diesel equipment.

Infrastructure Projects

Applicants purchasing a qualifying vehicle or piece of equipment under this grant program may request additional funding for onsite refueling infrastructure to fuel one or more of the qualifying vehicles of pieces of equipment.

Application Submission Limitations

Applicants will be subject to application submission limitations as defined in Section 4.1 of the Request for Grant Applications (RFGA). For the purposes of these limitations, “applicant” includes an individual or business and all of their associated legal affiliates. Applicants may not submit more than 10 activities in a single application and may not request more than $4 million in grant funds per calendar month that the program is open. Only one primary area, project type (replacement or repower), and/or emissions source (on-road or non-road) may be included per application.

Application Completeness

TCEQ will review applications for completeness. If an application is found to be incomplete, TCEQ will notify the applicant in writing and provide details about what is missing from the application. Applicants will be provided a deadline to submit the missing information to TCEQ.

Submission Instructions

Submit a completed and signed application form and the required attachments by uploading to TCEQ’s File Transfer Protocol Secure (FTPS) site, or submitting the application and associated documents by mail. All applications must be received by TCEQ no later than 5:00 p.m. Central Time, on the application submission deadline listed in the table below. Refer to Section 4.0 of the RFGA for detailed instructions for submitting an application. Use TCEQ’s FTPS site to submit your application securely (FTPS: A Step-by-Step Video Guide).

Please see Section 12 of this application for application submission instructions.

Important Dates Date

Program Opening Date June 3, 2024

Application Submission Deadline July 29, 2024

TCEQ-20332-a (Rev. June 2024) Page 1 of 22 https://ftps.tceq.texas.gov/ https://ftps.tceq.texas.gov/ https://www.youtube.com/watch?v=GW4eEe_uUwc

Section 1: Applicant Information

1. Legal Name of Individual or Entity Applying for the Grant

If selected for a grant, the legal name of the applicant will be used for contracting purposes.

Applicant Legal Name (Must Match W-9 Form)

2. Business Information

All business entities such as corporations or partnerships must have an active registration with the Texas Secretary of State by June 3, 2024, 5:00 p.m. CT. Businesses must maintain an active registration for the contract period.

Ownership / Business Type

Employer Identification Number (EIN)

Social Security Number (SSN) Individuals and Sole Proprietors Only

3. Small Business Information

Under this program, a Small Business is defined as a business owned by a person who owns and operates no more than five vehicles or pieces of equipment. At least one of those five vehicles must have been owned for more than two years and is:

a) an on-road heavy-duty diesel vehicle; or

b) a non-road diesel piece of equipment.

Does the applicant qualify as a small business?

TCEQ-20332-a (Rev. June 2024) Page 2 of 22 https://www.irs.gov/pub/irs-pdf/fw9.pdf

4. Authorized Official (AO)

The applicant or an employee who has legal authority to sign for and speak on behalf of the applicant.

AO First Name

AO Middle Initial

AO Last Name

AO Suffix (If applicable)

AO Title

AO Primary Phone Number

AO Secondary Phone Number

AO Email Address

AO Mailing Address (Street or PO Box)

AO City, State, and Zip Code

5. Designated Project Representative (DPR)

The applicant or an employee who will serve as the point of contact for this application.

Is the DPR the same person as the AO?

(If yes, select Yes and continue to Section 2.

If no, select No and enter DPR information.)

DPR First Name

DPR Middle Initial

DPR Last Name

DPR Suffix (If applicable)

DPR Title

DPR Primary Phone Number

DPR Secondary Phone Number

DPR Email Address

DPR Mailing Address (Street or PO Box)

DPR City, State, and Zip Code

Personal Information Policy: Individuals are entitled to request and review their personal information that the agency gathers on its forms. Individuals may request to have their provided personal information updated. To review such information, contact TERP program staff at TERP@tceq.texas.gov or 800-919-TERP (8377).

TCEQ-20332-a (Rev. June 2024) Page 3 of 22 mailto:TERP@tceq.texas.gov

Section 2: Third-Party Preparer Signature Page

1. Third-Party Preparer

A third-party preparer is someone other than the applicant or an employee of the applicant. If a third-party preparer was not used in the preparation of an application, select “No” from the dropdown list and proceed to Section 3.

Was this application prepared by a third party?

2. Third-Party Preparer Certification

I hereby certify to the best of my knowledge and belief that all information provided in this application, including any attachments, is true and correct, as represented to me by the applicant. I understand that failure to sign the application will make this application ineligible. I understand that making a false statement may cause the submitted application to be ineligible, may make any resulting contracts voidable, and may subject me to criminal and civil penalties.

3. Third-Party Preparer Information

Third-Party Preparer Printed Name (First Last)

Title

Company Name

Mailing Address (Street or PO Box)

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Email Address

Third-Party Preparer Signature*

Third-Party Preparer Signature Date

*If using an electronic signature instead of a typed signature, please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

TCEQ-20332-a (Rev. June 2024) Page 4 of 22

Section 3: Certification of Eligibility to Receive a State-Funded Grant All applicants must complete this section to certify eligibility to receive a grant under this program, even if child support obligations do not apply to the applicant. Failure to complete this section may result in rejection of the application.

Certification Regarding Child Support Obligations.

Under Section 231.006, Texas Family Code, a child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25%, is not eligible to receive a state-funded grant or loan. All applicants must include in the application the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of 25% or more of the business entity submitting the application.

Federal Privacy Act Notice: This notice is given pursuant to the Federal Privacy Act. Disclosure of your Social Security Number (SSN) is required under Section 231.006(c) and Section 231.302(c)(3) of the Texas Family Code. The SSN will be used to identify persons that may owe child support. The SSN will be kept confidential to the fullest extent allowed under Section 231.302(e) of the Texas Family Code.

Please Check One of the Following Applicant Options.

1. Individual or Sole Proprietor

2. One or more individuals own 25% or more of the business entity

3. No individual owns 25% or more of the business entity

4. Governmental Entity

If Option 1 or 2 is checked above, list the name(s) and social security number(s) below.

Name Social Security Number

Name Social Security Number

Name Social Security Number

Name Social Security Number

Applicant Certification By signing this application in Section 11: Project Summary Page, under Section 231.006 of the Texas Family Code, the applicant certifies that the individual or business entity named in this application is not ineligible to receive the specified grant and acknowledges that any contract may be terminated, and any payments may be withheld if this certification is inaccurate.

TCEQ-20332-a (Rev. June 2024) Page 5 of 22 https://statutes.capitol.texas.gov/Docs/FA/htm/FA.231.htm#231.006 https://www.justice.gov/opcl/privacy-act-1974 https://statutes.capitol.texas.gov/Docs/FA/htm/FA.231.htm#231.302 https://statutes.capitol.texas.gov/Docs/FA/htm/FA.231.htm#231.302

Section 4: Program Certifications This section includes specific requirements and statements for funding under the Rebate Grants Program. These terms apply to any contract awarded by TCEQ from this application. The Rebate Grants Program RFGA and the draft contract, located on the Rebate Grants Program webpage, contain additional terms and conditions that the applicant should review before submitting an application.

By signing this application, you understand and certify compliance with all the statements below, as well as with any state statutes, regulations, policies, guidelines, and requirements as they relate to the application, acceptance, and use of funds for this project. If any of these certifications materially change after submittal of the application, you will provide prompt written notification to TCEQ within three business days of becoming aware of the change. Failure to notify TCEQ and/or any changes to your certifications may make the application ineligible and may make any resulting contracts voidable. If awarded a grant, failure to comply with these certifications may result in TCEQ seeking repayment of grant funds.

Equipment and Activity Certifications

1. Ownership. The equipment the applicant proposes to replace or repower has been continuously owned, leased, or otherwise commercially financed by the applicant for the two years immediately preceding the application signature date. For on-road equipment, the applicant must have been listed as the owner on the title document or the lessee on the lease agreement for the preceding two years.

2. Operation and Registration. The equipment has been continuously located and used in Texas in its primary function in the routine operations of the applicant for the two years immediately preceding the application signature date. In addition, on-road equipment has been continuously registered for operation in Texas for the two years immediately preceding the application signature date. See Section 8 regarding apportioned registration.

3. Condition. The equipment is in good operating condition and capable of performing its primary function in the routine operations of the applicant at the time of application signature. To the best of the applicant’s knowledge, the equipment is capable of continuing to perform its primary function for at least five years from the application signature date, taking into account normal maintenance, repairs, and upkeep.

4. Continued Operation and Use. If the grant funds were not available, the applicant expects to otherwise continue to operate the equipment in Texas for at least five years from the application signature date, and the applicant otherwise would not have planned to replace the equipment.

5. Disposition. The applicant has the legal authority to complete the approved method of disposition of the equipment or engine being replaced. If selected for a grant, the grantee is responsible for completing the disposition of the old equipment and engines being replaced within 90 days after the reimbursement is issued by

TCEQ.

6. Not Otherwise Required. To the best of the applicant’s knowledge, the proposed activities are not required by any state or federal law, rule or regulation, memorandum of agreement, or other legally binding contract.

7. No Emissions Reductions Credits. Activities funded under this program are not eligible to generate marketable credits under state or federal emissions reduction credit averaging, banking, or trading programs. If the project is funded, the applicant waives, for all time, its right to claim or apply for any emissions reduction credits from the use of the equipment or low-emission technology funded under Rebate.

8. Not to Exceed 100% of Equipment Cost. The amount of the Rebate grant award plus any other public financial assistance, tax credits or deductions, or other grants may not exceed the total eligible costs of the equipment.

9. Duty to Use, Maintain, and Repair Equipment. If awarded a grant, the applicant agrees to replace or repower the old equipment and purchase new equipment as described in this application. The applicant agrees to use any grant-funded equipment as described in this application. The applicant will maintain and repair any grant-funded equipment to ensure it remains in good operating condition during the activity life.

10. Requirement to Monitor and Report. The applicant will monitor and report on the use of the grant-funded equipment over the designated activity life. The applicant agrees to provide all required information on the use of the equipment upon request of TCEQ.

TCEQ-20332-a (Rev. June 2024) Page 6 of 22 https://www.tceq.texas.gov/airquality/terp/rebate.html

11. Insurance Coverage. The applicant will maintain, for the term of the activity life, property loss insurance or self-insurance (for governmental entities only) coverage on any equipment acquired, leased, repowered, retrofitted, or constructed using these funds, in an amount equal or greater than the grant award.

Administrative and State Contracting Certifications

1. Legal Authority. The applicant has the legal authority in the State of Texas to apply for the grant. The applicant's governing body has authorized the filing of the application, understands these requirements and certifications, and has authorized the individual identified as the Authorized Official to act in connection with the application and to provide such additional information as may be required.

2. Conflict of Interest. The applicant has not given, offered to give, nor intends to give any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted application. All purchase decisions must be based on sound business decisions and arm’s length bargaining.

3. Nondiscrimination. The applicant will comply with all State and Federal statutes relating to nondiscrimination. If the applicant is an employer under the Texas Labor Code, it must not discriminate on the basis of race, color, disability, religion, sex, national origin, age, or genetic information in its employment decisions.

4. Risk Review. The applicant’s prior performance under other TCEQ contracts; its overall compliance history;

and any federal, state, or local enforcement action for violation of environmental laws or permit conditions may be considered in determining eligibility.

5. Texas Public Information Act. Information, documentation, and other material in connection with this solicitation or any resulting contract or grant may be subject to public disclosure pursuant to Chapter 552 of the Texas Government Code. In accordance with Section 2252.907 of the Texas Government Code, the applicant is required to make any information created or exchanged with the State pursuant to the contract and grant, and not otherwise excepted from disclosure under the Texas Public Information Act, available in a format that is accessible by the public at no additional charge to the State.

6. Debt to the State. The applicant is not indebted to the state nor has an outstanding tax delinquency. The applicant must comply with all State and Federal tax laws and fee requirements and is solely responsible for filing all State and Federal tax and fee forms.

7. Contract. The applicant understands that a PDF of the draft contract may be viewed and downloaded from the Rebate webpage. The draft contract is for reference only and contains terms and conditions which are standard provisions for grants awarded under this program. Any requested changes to the draft contract must be received by TCEQ no later than application submission deadline. However, the applicant further understands that TCEQ will not normally change the contract language in response to individual requests from applicants and is under no obligation to do so. TCEQ reserves the right to modify the draft contract terms as necessary due to statutory, rule, or policy changes. Modifications will be posted to the Rebate webpage and the Electronic State Business Daily.

a) Emissions Reductions. If awarded a grant, the applicant certifies that it will provide written notification to TCEQ within 30 calendar days of any termination of use, change in use, sale, transfer, or accidental or intentional destruction of grant-funded equipment during the activity life. The applicant further agrees that TCEQ may be entitled to the return of all or a prorated share of the grant funds for any loss of emissions reductions compared with the emissions reductions projected in awarding the grant.

b) Texas Grant Management Standards. In accordance with Chapter 783, Texas Government Code, if the applicant is a local government, state entity, or political subdivision, it will comply fully with the Texas Grant Management Standards (TxGMS). This includes compliance with the relevant sections of TxGMS when procuring goods and services under a resulting contract. For all other applicants, the Cost Principles and Selected Items of Cost under TxGMS apply to any resulting contract. These documents are available at: comptroller.texas.gov/purchasing/grant-management.

c) Procurement of Goods and Services. If this application results in a contract, all procurement transactions made with (or to be reimbursed by) grant funds must be conducted in a manner providing full and open competition. All purchase decisions must be based on sound business decisions and arm’s length bargaining, and purchases must be made without any real or apparent personal or organizational conflicts of interest as described in TxGMS.

TCEQ-20332-a (Rev. June 2024) Page 7 of 22 https://statutes.capitol.texas.gov/Docs/LA/htm/LA.21.htm https://statutes.capitol.texas.gov/Docs/GV/htm/GV.552.htm https://statutes.capitol.texas.gov/Docs/GV/htm/GV.552.htm https://statutes.capitol.texas.gov/Docs/GV/htm/GV.2252.htm#2252.907 https://www.tceq.texas.gov/airquality/terp/rebate.html https://www.tceq.texas.gov/airquality/terp/rebate.html https://statutes.capitol.texas.gov/Docs/GV/htm/GV.783.htm https://www.comptroller.texas.gov/purchasing/grant-management/

d) Grant Administration. The applicant will maintain an appropriate grant administration system to ensure that they meet all terms, conditions, and specifications of the grant, including these certifications and assurances.

e) Audit. Acceptance of funds under this program acts as acceptance of the authority of the State Auditor’s Office, or any successor agency, to conduct an audit or investigation in connection with those funds. The applicant or other entity that may receive funds directly or indirectly from TCEQ must provide the state auditor with access to any information the state auditor considers relevant to the investigation or audit.

Applicant will include this clause concerning the authority to audit funds received indirectly and the requirement to cooperate in any subcontract it awards.

8. Contracting with an Executive of a State Agency. Under Texas Government Code Section 669.003, relating to contracting with an executive head of a state agency, applicant represents that no person who, in the past four years, served as an executive of TCEQ or any other state agency, was involved with or has any interest in this application. If applicant employs or has used the services of a former executive head of TCEQ or other state agency, the applicant shall provide the following information: name of former executive, name of state agency, date of separation from state agency, position with applicant, and date of employment with applicant.

9. Debarment and Excluded Parties. The applicant certifies that the applying entity and its principals are eligible to participate in this transaction and have not been subjected to suspension, debarment, or similar ineligibility determined by any federal, state, or local governmental entity. The applicant also certifies that it and its principals are not listed on the State of Texas Debarred Vendor List maintained by the Texas Comptroller of Public Accounts, or the System for Award Management (SAM.gov) maintained by the General Services Administration as authorized by Executive Order No. 13224, “Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism,” published by the U.S. Department of Treasury, Office of Foreign Assets Control.

10. Abortion Funding Limitation. The applicant represents and warrants it is not an abortion provider or an affiliate of an abortion provider under Texas Government Code, Chapter 2273, Prohibited Transactions.

11. COVID-19 Vaccine Passport Prohibition. Under Section 161.0085 of the Texas Health and Safety Code, the applicant certifies that it is not ineligible to receive funds.

12. Disclosure Protections for Certain Charitable Organizations. If the applicant is a governmental entity, it represents and warrants that it will comply with Section 2252.906 of the Texas Government Code relating to disclosure protections for certain charitable organizations, charitable trusts, and private foundations.

Replacement and Repower Project Certifications For each vehicle or equipment category selected in Section 5, the following certifications apply. By signing this application, you are certifying the applicable eligibility requirements listed herein.

An on-road vehicle eligible for replacement or repower must:

a) be a heavy-duty on-road vehicle with a gross vehicle weight rating (GVWR) greater than 8,500 pounds (lbs.);

b) have a diesel engine certified to the United States (US) Environmental Protection Agency (EPA) or California Air Resources Board (CARB) heavy-duty engine emissions standards.

Non-road equipment eligible for replacement or repower must:

a) be powered by a diesel engine rated at 25 horsepower (hp) or greater;

b) have a diesel engine that is certified to the United States (US) Environmental Protection Agency (EPA) or California Air Resources Board (CARB) emissions standards for non-road engines;

A waiver may be submitted for any ownership, registration, and use requirements pursuant to Appendix B in the

RFGA.

TCEQ-20332-a (Rev. June 2024) Page 8 of 22 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.669.htm#669.003 https://comptroller.texas.gov/purchasing/programs/vendor-performance-tracking/debarred-vendors.php https://sam.gov/content/home https://www.govinfo.gov/content/pkg/FR-2001-09-25/pdf/01-24205.pdf https://statutes.capitol.texas.gov/Docs/GV/htm/GV.2273.htm https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.0085 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.2252.htm#2252.906

Section 5.1: Old Vehicle/Equipment Information Only one primary area (detailed in Section 7), project type (replacement or repower), and/or emissions source (on-road or non-road) may be included per application.

1. Old Vehicle/Equipment Information (i.e., the equipment proposed to be replaced or repowered)

Old Vehicle/Equipment Activity Number 001 002 003 004 005

Emission Source On-Road or Non-Road

Vehicle/Equipment Type

Vehicle/Equipment Make

Vehicle/Equipment Year

Last 4 Digits of Vehicle ID (VIN) or Full Equipment ID

Gross Vehicle Weight Rating On-Road Vehicles Only

Engine Make

Engine Model

Engine Model Year

Engine Horsepower Rating(bhp/hr) Non-Road Equipment Only

Engine ID/Serial Number

Fuel Type DIESEL DIESEL DIESEL DIESEL DIESEL

Engine Family Code (12-digit emissions code required for engines 2003 and newer)

Federal NOX Emissions (g/mi or g/bhp-hr)

TCEQ-20332-a (Rev. June 2024) Page 9 of 22

Section 5.2: New Vehicle/Equipment Information

1. New Vehicle/Equipment Information (i.e., the proposed new grant-funded vehicle, equipment, or engine)

New Vehicle/Equipment Activity Number 001 002 003 004 005

Vehicle/Equipment Type

Vehicle/Equipment Model Year

Engine Model Year

Fuel Type

Federal NOX Emissions (g/mi or g/bhp-hr)

2. Requested Grant Amount: Applicants may be eligible for up to 1) the maximum grant amount listed in the Rebate Grants tables or 2) 80% of the eligible incremental cost of the vehicle/equipment, whichever is less (defined in Section 3.3 of the RFGA).

Maximum Eligible Grant Amount from the Table

TCEQ-20332-a (Rev. June 2024) Page 10 of 22

Section 5.1 (cont.): Old Vehicle/Equipment Information Only one primary area (detailed in Section 7), project type (replacement or repower), and/or emissions source (on-road or non-road) may be included per application.

1. Old Vehicle/Equipment Information (i.e., the equipment proposed to be replaced or repowered)

Old Vehicle/Equipment Activity Number 006 007 008 009 010

Emission Source On-Road or Non-Road

Vehicle/Equipment Type

Vehicle/Equipment Make

Vehicle/Equipment Year

Last 4 Digits of Vehicle ID (VIN) or Full Equipment ID

Gross Vehicle Weight Rating On-Road Vehicles Only

Engine Make

Engine Model

Engine Model Year

Engine Horsepower Rating(bhp/hr) Non-Road Equipment Only

Engine ID/Serial Number

Fuel Type DIESEL DIESEL DIESEL DIESEL DIESEL

Engine Family Code (12-digit emissions code required for engines 2003 and newer)

Federal NOX Emissions (g/mi or g/bhp-hr)

TCEQ-20332-a (Rev. June 2024) Page 11 of 22

Section 5.2 (cont.): New Vehicle/Equipment Information

1. New Vehicle/Equipment Information (i.e., the proposed new grant-funded vehicle, equipment, or engine)

New Vehicle/Equipment Activity Number 006 007 008 009 010

Vehicle/Equipment Type

Vehicle/Equipment Model Year

Engine Model Year

Fuel Type

Federal NOX Emissions (g/mi or g/bhp-hr)

2. Requested Grant Amount: Applicants may be eligible for up to 1) the maximum grant amount listed in the Rebate Grants tables or 2) 80% of the eligible incremental cost of the vehicle/equipment, whichever is less (defined in Section 3.3 of the RFGA).

Maximum Eligible Grant Amount from the Table

TCEQ-20332-a (Rev. June 2024) Page 12 of 22

Section 6: Refueling Infrastructure Projects (optional)

Refueling Infrastructure Project Certifications This Section must be completed by applicants requesting grant funds for refueling infrastructure.

Site Ownership

Is the Applicant the Property Owner?

Applicants are required to be the owner of the site where the equipment is installed unless the applicant establishes permission to install and operate the grant-funded equipment at the site during the contract period.

The information below must be completed by the property owner if the applicant does not own the site where the equipment will be installed.

Property Owner Name

Authorized Official of Property Owner

Authorized Official Title

Phone Number

Email Address

Mailing Address (Street or PO Box)

City, State, and Zip Code

I, the undersigned owner or authorized official of the real property located at the address identified in the refueling infrastructure project location below, consent to the installation of the refueling infrastructure on this property. I understand and agree that the applicant is obligated, unless otherwise approved by TCEQ, to keep the refueling infrastructure in operation and in service for a minimum of five years after installation.

Property Owner or Authorized Official Signature*

Date

*If using an electronic signature instead of a typed signature, please complete the entire application before signing. The ability to edit, add, or remove information will not be available after the application is electronically signed.

Refueling Infrastructure Equipment Ownership

By signing this application, the applicant certifies that it will purchase and own the grant-funded equipment during the contract period subject to the following: Any sale of the grant-funded equipment during the contract period will be subject to approval and consent to assignment by TCEQ in accordance with the contract terms.

TCEQ-20332-a (Rev. June 2024) Page 13 of 22

Refueling Infrastructure Equipment Information This Section must be completed by applicants who are requesting grant funds to purchase and install refueling infrastructure for qualifying alternatively fueled vehicles or equipment detailed in Section 5 of this application. At least one qualifying vehicle or piece of equipment must operate on the fuel type selected in Part 1 of this Section. All grant-funded refueling infrastructure must be owned and operated by the applicant; leased equipment is not eligible.

1. Fuel Type and Information Select the fuel type from the drop-down box below:

Please list the number of dispensing units and the number of connectors or refueling nozzles.

Number of dispensing units Number of connectors or refueling nozzles

What is the charge rate (kW) or throughput rate (kg/day) of the refueling infrastructure?

Charge Rate # kW or kg/day

2. Project Location Please list the location of the proposed refueling infrastructure project.

Physical Address

City, State, Zip Code

County

3. Project Details Please briefly describe the proposed refueling infrastructure project below. Be sure to describe how this refueling infrastructure will support, at the very least, the qualifying vehicles or equipment detailed in this application, and the number of fueling or charging ports that will be installed. If this project will expand existing refueling infrastructure, please indicate this as well.

4. Required Documentation Applicants with projects that include refueling infrastructure must provide documentation that includes:

a) A site plan with the application (including a scaled map which could be a photograph, satellite map, drawing, or similar graphic of the proposed site) that shows the planning and design of the proposed facility. The site plan must:

i. Demonstrate how the vehicle or equipment may access the proposed facility; a nd

ii. Provide the location of the facility within the property and include any easements, set-back requirements, and property boundaries.

b) A demonstration of the applicant’s ability to install, operate and maintain the refueling infrastructure at the proposed site by providing documentation, such as property ownership records, lease agreements or other legal agreements, that can show the following:

i. The ability to complete any required construction on the proposed site; and

ii. The ability to operate on the proposed property for a length of time equal to the activity life of the grant-funded equipment (refer to Section 4.8 of the RFGA).

TCEQ-20332-a (Rev. June 2024) Page 14 of 22

5. Refueling Infrastructure Grant Amount

Please indicate the projected costs and requested grant amount in the space provided below. Refer to Section 3 of the RFGA to determine the maximum grant amount and eligible costs. Applicants may receive one of the following options, whichever is less:

a) $100,000 plus $100,000 for each grant-funded on-road vehicle or non-road piece of equipment that is fueled by the associated infrastructure in this application;

b) 50% of the eligible incremental cost for the purchase and installation of the refueling infrastructure; or

c) $600,000.

Equipment Total

Supplies and Materials Total

Construction Total

Contract Services Total

Total Eligible Project Costs

Refueling Infrastructure Grant Amount (the lesser of options a, b, or c above)

TCEQ-20332-a (Rev. June 2024) Page 15 of 22

Section 7: Operation of Grant-Funded Equipment ____ Check here if the unit of measurement and percent of annual operation is the same for all activities, and enter only under Activity 001.

For replacement and repower projects, at least 55% of the grant-funded vehicle or equipment annual operation must occur in one or more of the nonattainment areas and affected counties for the duration of the five-year activity life. A single unit of measurement (miles or fuel for on-road, hours for non-road) must be used for determining the total annual operation. If awarded a grant, the grantee will use this unit of measurement to report annual operation for the duration of the five-year activity life. Only one primary area may be included per application.

Identify the areas where the grant-funded vehicle or equipment will operate and provide the percent of annual operation in the space provided. At least 55% of the annual operation of each grant-funded vehicle or piece of equipment must occur in the eligible counties. To avoid overstating the total annual operation in the eligible counties, applicants must take into account any operation of the grant-funded vehicle or piece of equipment in ineligible counties. At the time of application, applicants may elect to increase this commitment to 80% of their annual operation to receive additional grant funds. Refer to Section 2.11 of the RFGA for operation requirements. Refer to Appendix A of the RFGA to see a map of the eligible areas and counties.

Activity 001 002 003 004 005

Activity Unit of Measurement

Nonattainment and Affected Counties Annual % Annual % Annual % Annual % Annual %

% of Annual Operation Austin Area Bastrop, Caldwell, Hays, Travis, and Williamson Counties % of Annual Operation Beaumont-Port Arthur Area

Hardin, Jefferson, and Orange Counties % of Annual Operation Corpus Christi Area

Nueces and San Patricio Counties % of Annual Operation Dallas-Fort Worth Area

Collin, Dallas, Denton, Ellis, Henderson, Hood, Hunt, Johnson, Kaufman, Parker, Rockwall, Tarrant, and Wise Counties

% of Annual Operation El Paso Area El Paso County

% of Annual Operation Houston-Galveston-Brazoria Area Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller

Counties % of Annual Operation San Antonio Area

Bexar, Comal, Guadalupe, and Wilson Counties % of Annual Operation Tyler-Longview Area

Gregg, Harrison, Rusk, Smith, and Upshur Counties % of Annual Operation Other Counties

Anderson, Freestone, Howard, Hutchinson, Navarro, Panola, and Titus Counties

Total Annual Operation

TCEQ-20332-a (Rev. June 2024) Page 16 of 22

Section 7 (cont.): Operation of Grant-Funded Equipment Identify the areas where the grant-funded vehicle or piece of equipment will operate and provide the percent of annual operation in the space provided. At least 55% of the annual operation of each grant-funded vehicle or piece of equipment must occur in the eligible counties. To avoid overstating the total annual operation in the eligible counties, applicants must take into account any operation of the grant-funded vehicle or piece of equipment in ineligible counties. At the time of application, applicants may elect to increase this commitment to 80% of their annual operation to receive additional grant funds. Refer to Section 2.11 of the RFGA for operation requirements. Refer to Appendix A of the RFGA to see a map of the eligible areas and counties.

Activity 006 007 008 009 010

Activity Unit of Measurement

Nonattainment and Affected Counties Annual % Annual % Annual % Annual % Annual %

% of Annual Operation Austin Area Bastrop, Caldwell, Hays, Travis, and Williamson Counties % of Annual Operation Beaumont-Port Arthur Area

Hardin, Jefferson, and Orange Counties % of Annual Operation Corpus Christi Area

Nueces and San Patricio Counties % of Annual Operation Dallas-Fort Worth Area

Collin, Dallas, Denton, Ellis, Henderson, Hood, Hunt, Johnson, Kaufman, Parker, Rockwall, Tarrant, and Wise Counties

% of Annual Operation El Paso Area El Paso County

% of Annual Operation Houston-Galveston-Brazoria Area Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller

Counties % of Annual Operation San Antonio Area

Bexar, Comal, Guadalupe, and Wilson Counties % of Annual Operation Tyler-Longview Area

Gregg, Harrison, Rusk, Smith, and Upshur Counties % of Annual Operation Other Counties

Anderson, Freestone, Howard, Hutchinson, Navarro, Panola, and Titus Counties

Total Annual Operation

TCEQ-20332-a (Rev. June 2024) Page 17 of 22

Section 8: Apportioned Registration Mileage Summary (On-Road Equipment with Apportioned Registration Only)

For equipment with apportioned registration, this form is required to document mileage in Texas and out of state for the two years immediately preceding the application signature date. Intentional falsification of this form will be prosecuted to the extent allowed under the law and impact eligibility for future grants.

Activity 1 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 2 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 3 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 4 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 5 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 6 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 7 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 8 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 9 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

Activity 10 Miles In Texas: Miles Outside Texas: Total Miles:

Year 1

Year 2

By signing this document, I hereby certify that this information is true and correct.

Authorized Official Signature

Date of Signature

TCEQ-20332-a (Rev. June 2024) Page 18 of 22

Section 9: Disposition of Vehicle, Equipment, and Engine Being Replaced Disposition requires that the old equipment and engine be destroyed and rendered permanently inoperable and non-repairable. Unless otherwise approved by TCEQ, a grant applicant must agree to dispose of the equipment replaced under this program by Standard Disposition. Anything other than standard disposition must be preapproved by TCEQ and included in the contract as a Special Condition.

1. Method of Disposition

Mark the proposed method of disposition below.

Standard Disposition: Complete destruction or otherwise rendering permanently inoperable by crushing the equipment and engine, or cutting a 3-inch or larger hole in the engine block and cutting both frame rails in half. If you are proposing to use the standard method of disposition, continue to Section 10.

Alternative Disposition: TCEQ will consider alternative methods of rendering the equipment permanently inoperable in lieu of the standard method of destruction. If you are proposing to use an alternative method of disposition, continue to the subsections below.

2. Alternative Disposition

If the applicant is proposing an alternative method of disposition in lieu of the standard method of disposition outlined in Section 4.7 of the RFGA, explain in the space provided below.

3. Activities Selected for Alternative Disposition.

If the applicant is proposing an alternative method of disposition in lieu of the standard method of disposition outlined in Section 4.7 of the RFGA, please answer the questions below.

Does the alternative disposition apply to all vehicles, equipment, and engines listed in this application?

If No, list the activity numbers for which the proposal applies.

TCEQ-20332-a (Rev. June 2024) Page 19 of 22

Section 10: P roject Summary Page

1. Applicant Information

Applicant Legal Name

Applicant Type

Does Applicant Qualify as a Small Business?

If yes, the applicant certifies by signing below that it meets the small business criteria outlined in Section 2.3 of the RFGA.

Applicant Mailing Address

Street or PO Box

Applicant City, State, and Zip Code

2. Project Information

Primary Project Area

Emission Source

Project Type

Total Number of Activities in this Application (This number must match the number from Section 5)

Total Eligible Costs of Project (Total requested grant amount of all activities from Section 5)

Total Requested Grant Amount (Total requested grant amount of all activities from Section 5 plus Refueling Infrastructure Grant Amount from Section 6, if applicable)

3. Authorized Official The applicant or an officer or employee of the applicant who has the legal authority to sign on behalf of the applicant.

I hereby certify to the best of my knowledge and belief that all information provided in this application and any attachments is true and correct, including any representations made by a third-party preparer. My signature also constitutes acceptance of the certifications in Sections 4 and 6 of this application, the terms of the RFGA, and any other changes posted through addenda on the Electronic State Business Daily. I understand that failure to sign the application will make this application ineligible. I understand that any false statement may cause the submitted application to be ineligible, may make any resulting contracts voidable, and may subject me to criminal or civil penalties.

Printed Name of Authorized Official

Authorized Official Title

Signature of Authorized Official* Date of Signature

*If using an electronic signature instead of a typed signature, please complete the entire application before signing electronically. The ability to add, edit, or remove information will not be available after the application is electronically signed.

The application, signed by the Authorized Official, must be received by the application deadline or the application will not be accepted.

Upon submission, all proposals become the property of the State of Texas and as such become subject to the Texas Public Information Act, Texas Government Code Chapter 552.

TCEQ-20332-a (Rev. June 2024) Page 20 of 22 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.552.htm

Section 11: Application Checklist All applications for funding must be submitted within the application submission period listed on the cover page of the RFGA. A complete application must include:

• all pages of the application • applicant’s contact information

• all required attachments • all required signatures

Application Section Checklist (All Applications)

Section 1: Applicant Information

Section 2: Third-Party Preparer Signature Page Signature Required if application was prepared by a third party.

Section 3: Certification of Eligibility

Section 4: Program Certifications Review and include with the application.

Sections 5.1 Old Vehicle/Equipment Information and 5.2: New Vehicle/Equipment Information

Section 6: Refueling Infrastructure (optional)

Section 7: Operation of Grant-Funded Equipment

Section 8: Apportioned Registration Mileage Summary (if applicable) Signature Required.

Section9: Disposition

Section 10: Project Summary Page Signature Required.

Section 11: Application Checklist Complete and include with application.

Required Attachments Checklist (All Applications)

IRS Form W-9 Download, fill out entirely, and include with application. Signature Required.

Copy of State or Federal Identification If applying as an Individual or Sole Proprietor.

Copy of Registration Documents for Old Equipment

Include documentation of continuous registration for the 12 months immediately preceding the application signature date (on-road only).

Copy of Current Title or Lease Agreement for Old Equipment

Include documentation of ownership for the 2 years immediately preceding the application signature date (on-road only).

Color Photographs of Vehicle, Equipment, or Engine Being Replaced Labeled by Activity Number

Attach color photographs of the front, right side, left side, rear, engine and engine data plate of the vehicle, equipment, and engine being replaced.

Photographs should include tires or tracks.

Required Refueling Infrastructure Attachments Checklist (Applications with Refueling Infrastructure)

Site Plan Include with the application.

Site Property Rights or Ownership Documentation Include with the application.

Supplemental Forms (if applicable) Supplemental Form 1: Waivers of Please fill out entirely (if applicable) and include Program Requirements with application. Signature Required.

TCEQ-20332-a (Rev. June 2024) Page 21 of 22 https://www.irs.gov/pub/irs-pdf/fw9.pdf

Section 12: Application Submission Instructions Electronic Application Submissions Applications may be submitted securely by uploading the file to TCEQ's FTPS Server and selecting the share file(s) button. Enter Rebate-Apply@tceq.texas.gov as the email address. See detailed directions for using TCEQ’s FTPS site. Please note: Applications uploaded to TCEQ’s FTPS server without completing the share file(s) step will not be considered as submitted. Learn how to create an account and submit your application via the FTPS site in this step-by-step video guide. It is preferable that the application and its attachments be submitted as a single PDF, but it is not required. If the attachments for an application will be submitted as separate files, each attachment must be grouped by activity and clearly labeled with the activity number at the top of each page.

Physical Application Submissions Applications may also be submitted by mailing a physical copy to one of these addresses:

Standard Mail:

Texas Commission on Environmental Quality Air Grants Division, MC-204 (Rebate) P.O. Box 13087 Austin, TX 78711-3087

Express Mail:

Texas Commission on Environmental Quality Air Grants Division, MC-204 (Rebate) 12100 Park 35 Circle, Building F, 1st Floor, Suite 1301 Austin, TX 78753

TCEQ-20332-a (Rev. June 2024) Page 22 of 22 https://ftps.tceq.texas.gov/ https://ftps.tceq.texas.gov/help/ https://ftps.tceq.texas.gov/help/ https://www.youtube.com/watch?v=GW4eEe_uUwc https://www.youtube.com/watch?v=GW4eEe_uUwc mailto:Rebate-Apply@tceq.texas.gov