ESBD_File_343776_582-24-50564-HD THIVE Refueling Infrastructure App FINAL.pdf

Project Application Form Refueling Infrastructure Projects

Texas Hydrogen Infrastructure, Vehicle, and Equipment Grant Program (THIVE)

Texas Commission on Environmental Quality (TCEQ) Texas Emissions Reduction Plan (TERP)

Solicitation No. 582-24-50564-HD

Esta es la aplicación de subvención para el Programa de Subsidios de Infraestructura, Vehículos y Equipos de Hidrógeno de Texas (THIVE por sus siglas en Inglés). Debe llenar y enviar esta aplicación para solicitar una subvención. Comuníquese al 800-919-TERP (8377) para obtener ayuda con esta solicitud.

TCEQ invites applications for the THIVE Grant Program. THIVE provides funding to offset the cost of adopting hydrogen infrastructure, vehicles, and equipment to reduce Nitrogen Oxide (NOx) emissions from high-emitting sources in Texas nonattainment areas and affected counties.

Refueling Infrastructure Projects: This project application form should only be completed by applicants seeking to install and implement new hydrogen charging or refueling infrastructure.

Application Submission Limitations: Applicants may be subject to application submission limitations as defined in Section 4.1 d) of the RFGA. For the purposes of these limitations, “applicant” includes an individual or business and all of their associated legal affiliates.

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.

Public Information Notice: Upon submission, all proposals become the property of the State of Texas and subject to the Texas Open Records Act, Texas Government Code, Chapter 552.

How to Submit an Application: If you have questions on how to fill out this form, please contact us at 1-800-

919-TERP (8377).

1. Only one refueling infrastructure project at a single location may be submitted per application.

2. Submit a completed and signed application form and the required attachments by emailing to THIVE- Apply@tceq.texas.gov, 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, February 27, 2024. Please note: submission via standard email may not be secure. Use TCEQ’s FTPS site to submit your application securely. Learn how to create an account and submit your application via FTPS (FTPS: A Step-by-Step Video Guide).

Key Events Date and Time

Program Opening Date November 29, 2023

Application Submission Deadline February 27, 2024

TCEQ-20976/c (Nov. 2023) Page 1 of 12 mailto:THIVE-Apply@tceq.texas.gov mailto:THIVE-Apply@tceq.texas.gov https://www.tceq.texas.gov/airquality/terp/thive https://www.tceq.texas.gov/airquality/terp/thive https://www.youtube.com/watch?v=GW4eEe_uUwc

Section 1: Applicant Information

1. Legal Name of 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 November 29, 2023, 5:00 p.m. CT. Businesses must maintain an active registration for the contract period.

Ownership / Business Type:

Federal Employer Identification Number (FEI):

Social Security Number:

Individuals and Sole Proprietors only

3. Authorized Official (AO) The applicant or an employee who has legal authority to sign for and speak on behalf of the entity.

AO First Name:

AO Middle Initial:

AO Last Name:

AO Suffix (If applicable):

AO Title:

AO Primary Phone Number:

AO Cell Phone Number:

AO Email Address:

AO Mailing Address (Street or PO Box):

AO City, State, and Zip Code:

4. 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 the DPR is the same as the AO, select Yes and continue to Section 2.

Otherwise, enter DPR information)

DPR First Name:

DPR Middle Initial:

DPR Last Name:

DPR Suffix (If applicable):

DPR Title:

DPR Primary Phone Number:

DPR Cell Phone Number:

DPR Email Address:

DPR Mailing Address (Street or PO Box):

DPR City, State, and Zip Code:

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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:

Cell Phone Number:

Email Address:

Third-Party Preparer Signature*:

Third Party 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.

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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

Name Social Security Number

Applicant Certification By signing this application in Section 8: 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.

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Section 4: General Certifications This section includes specific requirements and statements for funding under the THIVE Grant Program. These terms apply to any contract awarded by TCEQ from this application. The THIVE Grant Program RFGA and the draft contract, located on the THIVE Grant 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.

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 person 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. 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.

4. 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.

5. Debarment. 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) 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.

6. Nondiscrimination. The applicant will comply with all State and Federal statutes relating to nondiscrimination.

7. 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.

8. 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 252.907 of the Texas Government Code, 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.

9. 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.

10. 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.

11. 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.

12. Contract. The applicant understands that a PDF of the draft contract may be viewed and downloaded from the THIVE 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 the date of the submission of this application. However, the applicant further understands that TCEQ will not normally change the contract language in response to individual requests from grant recipients 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 THIVE webpage and the Electronic State Business Daily.

TCEQ-20976/c (Nov. 2023) Page 5 of 12 https://www.tceq.texas.gov/airquality/terp/thive https://www.tceq.texas.gov/airquality/terp/thive

a. 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 vehicles 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 selected items of cost of TxGMS apply to any resulting contract. These documents are available at: https://www.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.

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

e. Audit. Acceptance of funds under this program acts as acceptance of the authority of the State Auditor’s Office (SAO), 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 SAO with access to any information the SAO 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.

TCEQ-20976/c (Nov. 2023) Page 6 of 12 https://www.comptroller.texas.gov/purchasing/grant-management/ https://www.comptroller.texas.gov/purchasing/grant-management/

Section 5: Program Certifications

Refueling Infrastructure Project Certifications For the hydrogen refueling infrastructure project listed in Section 7, the following certifications apply. By signing this application, you are certifying the applicable eligibility requirements listed herein.

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:

Title:

I, the undersigned owner of the real property located at the address identified in Section 7.2: Refueling Infrastructure Information 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 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.

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Section 6: Application Score Tie-breaking Provisions Tie-breaking provisions – In the event of a tied score, the following will be used as tiebreakers in no order of preference.

Please select all that are applicable and include documentation as an attachment to the application:

� Applicant is (or is owned by) a service-disabled veteran who is a Texas resident. (Tex. Gov. Code 2155.444).

� Applicant is a Texas bidder meaning it is incorporated in this state; has its principal place of business in this state;

or has established a physical presence in this state. (Tex. Gov. Code 2155.444).

� Applicant will use USA-produced supplies, materials, or equipment in fulfilling its grant obligations. (Tex. Gov.

Code 2155.444).

� Applicant is a Historically Underutilized Business (Tex. Gov. Code 2155.505).

� Applicant is a Women-Owned Small Business as defined by the of the United States Small Business Administration.

� Applicant is a Veteran-Owned Small Business or Service-Disabled Veteran Owned Small Business.

� Applicant is a Disadvantaged Business Enterprise (DBE) as defined by the United States Department of Transportation.

� Applicant is a Small Business Concern as defined by the regulations of the United States Small Business Administration in 13 C.F.R. Section 121.201. (Tex. Gov. Code 2155.505).

� Applicant will use products made of recycled, remanufactured, or environmentally sensitive materials in fulfilling its grant obligations. (Tex. Gov. Code 2155.445).

� Applicant will purchase and use energy efficient products in fulfilling its grant obligations. (Tex. Gov. Code 2155.442).

� Applicant will purchase and use products made by persons with disabilities in fulfilling its grant obligations. (Tex.

Gov. Code 2155.441).

� Facility will be located on formerly contaminated property. (Tex. Gov. Code 2155.450).

� Facility will be in an economically depressed or blighted area. (Tex. Gov. Code 2155.449, 2306.004).

� None of the above.

TCEQ-20976/c (Nov. 2023) Page 8 of 12

Section 7: Refueling Infrastructure Information This project application must be completed by applicants who are requesting grant funds to purchase and install hydrogen refueling infrastructure. All grant-funded refueling infrastructure must be owned, operated, and maintained by the applicant within an eligible county for the duration of the grantee’s five-year usage reporting requirement. Leased equipment is not eligible.

When determining the requested grant amount in Part 5 of this Section, applicants should refer to Section 3 of the RFGA to determine the maximum grant amount and eligible costs. An applicant may request up to 50% of the eligible costs of the hydrogen refueling or fuel cell charging infrastructure project.

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

Infrastructure Fuel Source:

What is the refueling (throughput) rate, in kilograms per day (kg/day), of the refueling infrastructure?

kg/day:

2. Infrastructure Project Location Please list the location of the proposed refueling infrastructure project. Refer to Appendix A of the RFGA for a list of eligible counties.

Physical Address:

City:

State:

Zip Code:

County:

3. Infrastructure Project Details Please briefly describe the proposed refueling infrastructure project below. If this project will expand existing refueling infrastructure, please indicate this as well.

4. Required Documentation Applicants with refueling infrastructure projects 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 vehicles or equipment may access the proposed facility to refuel; and

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 the duration of the contract if awarded a grant.

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5. Infrastructure Grant Amount For refueling infrastructure projects, applicants must submit with the grant application an estimated budget outlining the eligible project costs. Please indicate the projected costs and requested grant amount in the space provided below. Refer to Section 3.0 of the RFGA to determine the maximum grant amount and eligible costs. Applicants may request a maximum of 50% of the eligible costs of the hydrogen refueling or fuel cell charging infrastructure project.

Equipment Total (A):

Supplies and Materials Total (B):

Construction Total (C):

Contract Services Total (D):

(minus) Other Financial Incentives and Tax Credits (E):

Refer to section 3.3 of RFGA

Total Eligible Project Costs (F):

(A+B+C+D-E)

Refueling Infrastructure Grant Amount:

Requested grant amount may not exceed 50% of (F).

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Section 8: Project Summary Page

1. Applicant Information Applicant Legal Name:

Applicant Type:

Applicant Mailing Address:

(Street or PO Box)

Applicant City:

Applicant State:

Applicant Zip Code:

2. Project Information Primary Project Area:

Project Category: Hydrogen Refueling Infrastructure

Project Type:

Total Eligible Costs of Project:

(Total eligible costs from Section 7)

Total Requested Grant Amount:

(Total requested grant amount from Section 7)

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

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 5 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.

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 1-800-919-TERP (8377).

TCEQ-20976/c (Nov. 2023) Page 11 of 12 mailto:TERP@tceq.texas.gov

Section 9: 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;

• all required attachments;

• applicant’s contact information;

• all required signatures; and

• any additional supporting documentation.

Application Section Checklist (All Applications)

Section 1: Applicant Information Please fill out entirely.

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

Section 3: Certification of Eligibility Please fill out entirely.

Section 4: General Certifications Please read and include with application.

Section 5: Program Certifications Please read and include with application.

Signature required if applicable.

Section 6: Application Score Tie-breaking Provisions Please fill out entirely.

Section 7: Refueling Infrastructure Please fill out entirely.

Section 8: Project Summary Page Please fill out entirely. Signature Required.

Section 9: Application Checklist Please fill out entirely and include with application.

Required Attachments Checklist

IRS Form W-9 Download, fill out entirely. Signature Required.

Copy of State or Federal Identification Card Include only if applying as an Individual or Sole Proprietor.

Application Score Tie-breaking Documentation Please provide documentation of all selected criteria.

Required Refueling Infrastructure Attachments Checklist

Site Plan Include with the application.

Site Property Rights or Ownership Documentation Include with the application.

Budget Estimate of Eligible Costs Include with the application.

TCEQ-20976/c (Nov. 2023) Page 12 of 12 https://www.irs.gov/pub/irs-pdf/fw9.pdf