2018 Fleet Permission Form - Minnesota Clean Diesel Grant Program - Diesel Emissions Reduction
Total Page：16
File Type：pdf, Size：1020Kb
2018 Fleet permission form Minnesota Clean Diesel Program Diesel Emissions Reduction Act (DERA) Doc Type: Application
Instructions: Please fill out and return this form with your application packet if the vehicles/equipment for which you are applying are leased.
Applicant information
Applicant name: Date: (mm/dd/yyyy) Brief project description (Two to three sentences):
Fleet owner information
Vehicle/Equipment owner name: *Phone number: Address City: State: Zip code: *Please note: The fleet owner may be contacted by Minnesota Pollution Control Agency (MPCA) staff to verify permission.
Fleet description (One sentence):
Certification
As owner of, I hereby grant permission for to modify. the indicated equipment with , if they are successful in obtaining Minnesota Clean Diesel Grant Funds, in order to reduce diesel emissions.
Fleet owner verification: Print name: Date (mm/dd/yyyy): Title:
www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • Use your preferred relay service • Available in alternative formats p-f3-25-fy18 • 11/17/17 Page 1 of 1