Cycle 2 (FYE 2016) Charge! Program Application Form

Application packages must be submitted to the Air District BOTH electronically (online) and as a hard copy (one copy). Grant applications will be accepted on a first-come, first-serve basis through Friday, January 15, 2016 (by 4 PM), unless funds are exhausted sooner. Only complete applications will be evaluated. Please refer to the Charge! Program website for complete program eligibility requirements and instructions.

This application works best using Google Chrome or Mozilla Firefox browsers. Please do not use the backward/forward button of the browser to navigate through the application; this will cause data to be lost. Instead, click on the page numbers on the upper right of the page or use the buttons on the bottom to go to the desired page.

* Indicates required field.

PART 1. APPLICANT INFORMATION

Legal Name of Applicant/Organization

Doing Business As

Project Title

May be modified by the Air District.

APPLICANT'S ADDRESS

Legal Address

Street Address Line 2

City

State

Zip

Do you have a mailing address different from above?

YesNoAll official documents regarding this grant will be sent to the legal address unless a mailing address is provided.

Mailing Address

Mailing Address Line 2

City

State

Zip

CONTACT INFORMATION

Project Contact

This person serves as the point of contact for day-to-day communications.

Name of Project Contact

Project Contact Position/Title

Project Contact Email Address

Project Contact Phone Number

Is the person authorized to sign documents the same as Project Contact

YesNo

Authorized Signatory

This person is authorized to sign the application and execute grant funding agreements.

Authorized Signatory Name

Authorized Signatory Position/Title

Authorized Signatory Email Address

Authorized Signatory Phone Number

Is the person completing the application the same as Project Contact?

YesNo

Person Completing Application

Person Completing Application Name

Person Completing Application Position/Title

Person Completing Application Email Address

Person Completing Application Phone Number

For additional information contact us by email at grants@baaqmd.gov (subject "RE: Charge! Program") or by phone at 415-749-4994. For a complete listing of Program Requirements, click here.

PART 2. PROJECT INFORMATION

If the project includes more than one charging facility, then Section II. must be completed for each distinct facility. To add another charging facility, click on "Add Another Facility" on the bottom of the section.

I. Project Schedule

Please provide the proposed Project schedule. For the Project Start Date, indicate when work will commence (e.g., apply for permits, initiate CEQA, place order for equipment). For Project Open Date, indicate when all of the installation work for this project will be complete and all of the facilities that are part of this project will be open and available for use.

Project Start Date

Project Open Date

II. Facility Information

A. FACILITY LOCATION

Facility Address

City

Zip

County

Is the parking area new or existing?

New charging station(s)/Upgrade existing charging station(s)

Upgrades are defined as projects that propose to increase the number of charging ports on existing charging stations.

Open to the public?

YesNo

Easily and safely accessible, with adequate lighting?

YesNo

Does applicant have authorization to construct a charging station on the property?

YesNoi.e. site is owned by applicant, applicant has signed agreement with owner, applicant has a memorandum of understanding

Does applicant own the property?

Facility Category

Destination

This category is for destinations that may attract people to travel “medium-to-long” distances from their home and where the vehicle would tend to be parked for more than one hour. Examples of this category include shopping and retail/commercial centers, recreational areas, restaurants, theaters, stadiums, amusement parks, museums, and airports.

Provide key points of interest and their distance from the facility.

Provide an estimate of the number of drivers (including conventional vehicle and electric vehicle drivers) that visit the location on an annual basis. Provide information on how your total was calculated.

Workplace

This category may provide an alternative to residential charging for plug-in electric vehicle (PEV) drivers that may not have access to residential charging.

Provide a listing of the employer(s) that proposed charging station(s) will serve.

Provide an estimate of the number of PEVs that visit the facility on an annual basis. Provide information on how your total was calculated.

Provide a description of how you will facilitate maximum use of the charging station(s).

Would charging station(s) also service a business fleet (i.e., vehicles owned and operated by an employer)?

YesNo

Multi-Dwelling Unit (MDU)

This category includes a broad range of building complexes, from condominiums to high-rise apartments. MDUs may have parking associated with each unit, or parking only available through commercial lots in close proximity to the complex.

Who manages the parking?

Homeowner's Association (HoA)Property management companyParking management companyOther

If other, please specify:

Is parking attached to the unit?

Yes, it is attached.No, it is not attached.

Is parking deeded, assigned, or open?

DeededAssignedOpen

Number of units in the MDU?

Provide an estimate of the number of plug-in electric vehicles (PEVs) that will use the facility on an annual basis. Provide information on how your total was calculated.

Will each charging station be assigned to one unit or shared with multiple units?

If the chargers are assigned to multiple units, provide a description of how you will facilitate maximum use of the station.

Transportation Corridor

This category refers to charging at a location along a freeway or highway between the origin and destination of a trip with a distance longer than the typical electric vehicle driving range. Transportation Corridor charging gives existing and prospective electric vehicle owners the assurance that they can charge when driving long distances along a freeway or highway. These chargers may also be able to support the needs of local electric vehicle drivers.

Identify all heavy volume expressways, highways, and freeways within a one-mile driving distance from the proposed facility.

Provide distance to the next closest existing DC Fast station. NOTE: If existing station is closer than a 10-mile driving distance to the proposed facility, please provide evidence that the nearest existing location is not sufficient to meet the demand for charging at the proposed facility OR that the nearest existing location does not serve the corridor.

Provide the following total number of existing charge ports at the proposed facility:

Number of existing Level 1?

Number of existing Level 2?

Number of existing Low kW DC Fast?

Number of existing DC Fast?

Are you requesting a case-by-case evaluation for this facility? Only projects that do not meet the charging type listed in the Guidance, may be funded on a case-by-case basis. If yes, please upload additional information that may help us evaluate your project on the next page.

Yes, for other charger types.Yes, for lower usage requirements.Yes, for chargers serving TFCA-funded fleets.No

If yes, please explain:

Are you requesting additional funding or "Bonus" for Solar or Wind power generation at this facility? Note: Pre-existing solar or wind installation will not qualify for additional funding.

Yes, I am requesting the bonus for Solar or Wind power.No

Bonus for Solar or Wind

Describe the on-site zero-emission technology (e.g., solar, wind) you will use to off-set the demand of the chargers on the grid. What is the estimated annual energy generated or the storage capacity of the proposed technology?

Will the charging station(s) supported by the technology be connected to the grid? If not, describe how charging station(s) will meet the usage requirements.

B. CHARGER INFORMATION

Total Eligible Cost

Provide a budget below for this facility broken out by charger type. The Air District will determine your match requirement (%) based on cost information provided in this application.

Charger Type	Charger Quantity	# of ports/charger	Request/Charger ($)	Solar/Wind Bonus Request/Charger ($)	Dual Port Bonus Request/Charger ($)	Total Request/ Charger ($)	Total Request ($)	Total Eligible Cost ($)
For Transportation Corridor Sites: Level 2 Chargers may only be installed in conjunction with DC Fast Chargers.			Refer to Program Requirements for limits.	Refer to Program Requirements for limits.	Refer to Program Requirements for limits.	charger + solar + dual port		Refer to Program Requirements for instructions on how to determine what costs are eligible and what costs are ineligible.

Discounts, Credits, & Non-Air District Grants/Rebates

Provide a list of ALL discounts, credits, and non-Air District grants/rebates by source and by charger type. If these funds are derived from more than a single source, specify each funding source and the amount on a separate line. Air District will subtract these funds from your Eligible Cost to determine award amount. Refer to the FAQ for more information about how award amount is determined.

	Source	Amount ($)	Funding Status	Charger Type

Total Eligible Cost of this Facility:

$

Total Request for this Facility:

$

C. IMPACTED COMMUNITIES & PRIORITY AREAS

As part of the evaluation criteria, projects in PDA or CARE areas will receive high priority.

Is the station located in a Bay Area CARE Area?

YesNo

Using this map or this online map, please use the map to identify which CARE Area the project will operate in. BAAQMD staff may request that the grant applicant provide documentation to verify the information provided below.

	Code
CARE Area

Will the service operate in a designated Planned or Potential Priority Development Area (PDA)?

YesNo

Using the map, please indicate in the table below the Priority Development Area. Use the “zoom in” tool to enlarge the map to best identify boundaries and PDA codes.

	Code	PDA Type
PDA

For additional information contact us by email at grants@baaqmd.gov (subject "RE: Charge! Program") or by phone at 415-749-4994. For a complete listing of Program Requirements, click here.

TOTAL ELIGIBLE COST OF PROJECT

$

TOTAL PROJECT REQUEST

$

PART 3. SUPPLEMENTAL DOCUMENTS

1. Evidence of Authority to Apply & Implement

A signed letter of commitment from an individual with authority to enter into a financial commitment and carry out the Project (e.g., Chief Executive or Financial Officer, Executive Director, City Manager);

OR

A signed resolution from the governing board (e.g., City Council, Board of Supervisors, Board of Directors).

The signed letter of commitment or resolution must address the following:
Authorize the submittal of the application.
Confirm that the entity has secured matching funds from a non-Air District source(s) that would fund the costs to purchase/install and maintain the vehicle charging station in excess of the award amount.
Acknowledge that the entity will operate and maintain the station for its intended purpose for a minimum of three years.

2. Copy of Cost Estimate from Licensed Contractor

A copy of the estimate to construct the charging station with contractor license number. As part of the estimate, include specification sheet of charging equipment. Submit a cost estimate for each facility.

3. Map of Proposed Locations

Map showing the location in detail for each proposed location. Map must show 1) proximity to nearest roadway, 2) proximity to buildings, and 3) proximity to existing charging stations. If proposed locations are in multiple non-congruent areas, it is ideal to upload multiple maps as one PDF file.

4. Proof of Authority to Install & Operate

A copy of the memorandum of understanding (MOU), contract with charging station site host/owner, or other documentation.

5. Proof of Insurance

Proof of insurance as described in Appendix A of the Guidance.

6. Additional Information

Additional information to help us evaluate your project. Note: If you are requesting a case-by-case evaluation, please provide additional information.

For additional information contact us by email at grants@baaqmd.gov (subject "RE: Charge! Program") or by phone at 415-749-4994. For a complete listing of Program Requirements, click here.