Large-Spark Ignition Application

LARGE-SPARK IGNITION APPLICATION Please fill out one application for each engine or piece of equipment. All information necessary for completing this application is available in the Carl Moyer Program Guidelines (Release date: January 6, 2006). This document can be viewed at http://www.arb.ca.gov/msprog/moyer/guidelines/current.htm Please print clearly or type all information on this application.

Eligibility Criteria

To be eligible for funding, projects must meet the criteria described in the 2006 Carl Moyer Program Guidelines and the 2006 Carl Moyer Program Advisories. These criteria include but are not limited to the following:

 Emission reductions obtained through Carl Moyer Program projects must not be required by any federal, state or local regulation, memorandum of agreement/understanding with a regulatory agency, settlement agreement, mitigation requirement, or other legal mandate.

 Projects must meet a cost-effectiveness of $14,300 per weighed ton of NOx + ROG + twenty times combustion PM10 reduced, calculated in accordance with the cost-effectiveness methodology discussed in the Guidelines.

 No emission reductions generated by the Carl Moyer Program shall be used as marketable emission reduction credits, or to offset any emission reduction obligation of any person or entity.

 No project funded by the Carl Moyer Program shall be used for credit under any federal or state emission averaging banking and trading program.

 All engines in new vehicle purchases and repower projects must be certified by the ARB for sale in California and must comply with durability and warranty requirements.

Funding Disclosure

Has the engine or vehicle in this application been awarded funding from another public agency or being considered for funding?  Yes  No

If “yes”, complete the following for each engine or vehicle: State of California Air Resources Board MSCD/ORCB/CMP_26 Agency applied to ______Date of application submittal ______Funding amount requested ______Baseline engine serial number ______Status of application ______

A. APPLICANT INFORMATION (required) 1. Company or organization name:

2. Business type: 3. Contact name and title:

4. Person who filled out funding application:

4. Person with contract signing authority (if different from above):

5. Business mailing address and contact information:

Street: City: State: Zip code: Phone: ( ) Fax: ( ) E-mail: 6. Project address (if different from above):

7. How many engines are being applied for?

8. Total funding amount requested for this engine/equipment:

I hereby certify that all information provided in this application and any attachments are true and correct.

Printed name of responsible party: Title:

Signature of responsible party: Date:

Third Party Certification I have completed the application, in whole or in part, on behalf of the applicant. Printed name of third party: Title:

MSCD/ORCB/CMP_26 B-2 Signature of third party: Date:

Amount paid to third party: Source of funding to third party:

B. EQUIPMENT INFORMATION (required) 1. Forklift will be for: existing operation or facility, facility expansion, or new facility operations (select one): 2. Does the applicant rent/lease forklift to others?

3a. Equipment make: b. Equipment model: c. Equipment model year: 4. Equipment serial number:

5. Maximum rated lift capacity (pounds):

6. Forklift class:

C. ACTIVITY INFORMATION 1. Will the piece of equipment have a functioning hour meter for the full project life? (yes/no):

2. Annual hours of operation or annual gallons fuel consumption: 3a. Percent operation in California: b. Percent operation in district: 4. Project life:

D. ELECTRONIC MONITORING UNIT (EMU) 1a. EMU make: b. EMU model: c. EMU model year: d. EMU identification number:

e. EMU cost (optional): 2. Will a new eligible EMU be installed as part of this project? (yes/no):

MSCD/ORCB/CMP_26 B-3 E. ADDITIONAL INFORMATION – NEW PURCHASE ONLY 1. Engine family: 2. Engine make: 3. Engine model: 4. Engine year: 5. Fuel type:

6. Engine serial number:

7. Engine tier:

8. Baseline equipment cost:

9. New equipment cost:

F. ADDITIONAL INFORMATION – REPOWER ONLY Baseline Engine Information 1. Fuel type: 2. Engine make: 3. Engine model: 4. Engine model year: 5. Engine serial number: 6. Engine horsepower:

7. Engine tier: 8. Engine remanufacture cost:

Reduced Engine Information 1. Fuel type: 2. Engine make: 3. Engine model: 4. Engine model year: 5. Engine serial number: 6. Engine horsepower:

7. Engine tier: 8. Newer engine cost:

9. Newer engine installation cost:

MSCD/ORCB/CMP_26 B-4 G. ADDITIONAL INFORMATION – RETROFIT ONLY 1. ARB-verified retrofit device name: 2. Retrofit device make: 3. Retrofit device serial number: 4. Verification level:  LEVEL1  LEVEL 2  LEVEL 3 5. ARB-verified NOx reduction (%):

6. ARB-verified PM reduction (%):

7. ARB-verified ROG reduction (%):

8. Retrofit device ARB executive order:

9. Retrofit device cost:

10. Cost of retrofit device installation cost (optional):

11. Cost of retrofit maintenance over life of project (optional):

MSCD/ORCB/CMP_26 B-5