CUSTOM REBATE WORKSHEET
HIGH EFFICIENCY BATTERY CHARGER RETROFIT
COM
1.
Custom Efficiency rebates are for new energy-saving equipment and projects that are
not eligible for a standard rebate. Please provide the information below to help us to
determine your rebate amount.
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In addition to this form, you must submit a completed Custom Rebate Application (right)
with all invoices, receipts, and specification sheets. All Custom Rebate Terms and Conditions
apply. See the Commercial Custom Efficiency Rebate Application for details.
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Post-I
TOTAL
1. CUSTOMER INFORMATION
Account Number
Contact Name
Contact Phone Number
2. EQUIPMENT INFORMATION –
Number of Battery Cells
S
o NO
$
NT
(please print)
Account Name
Operational Information
A
o YE
OU
TE AM
REBA
Contact E-mail
Valid for retrofit applications only.
B
C
D
E
F
Battery Rated Amp Hours
Charge Cycles per Day
Charge Days per Year
Charge Time (Hours)
% non-charge time with no battery
1.
2.
Existing Charger Information
G
Manufacturer
H
I
J
K
L
Model
Type*
Quantity
AC Voltage (3-phase)
AC Input Amps
1.
2.
*Types: Ferroresonant, SCR, Hybrid, High Frequency
New High Efficiency Charger Information
M
N
Manufacturer
Model
O
P
Q
R
Type*
Quantity
AC Voltage (3-phase)
AC Input Amps
1.
2.
*Type: High Frequency
OFFICE USE ONLY
Date Received________________
Pre-Inspected?
o YES
o
NO
Date________________ Initials__________
Post-Inspected?
o YES
o NO
Date________________ Initials__________
TOTAL REBATE AMOUNT
$
Printed on Recycled Paper
0313