GOODS MOVEMENT EMISSION REDUCTION PROGRAM APPLICATION (Year 4)
FORM A4: Engine Repower – Heavy-Duty Trucks (Complete 1 Form per truck)
I. EXISTING TRUCK AND ENGINE INFORMATION
Truck Information
Drayage and “Dray-off” trucks are NOT eligible for funding
 "Drayage and Dray-off Trucks" are defined by Section C.15 of the Drayage Truck Regulation (13 CCR §2027) which states that any in-use on-road vehicle with a
gross vehicle weight rating (GVWR) greater than 26,000 pounds that is used for transporting cargo, such as containerized, bulk, or break-bulk goods, that
operates:

(A) on or transgresses through port or intermodal rail yard property for the purpose of loading, unloading or transporting cargo, including transporting
empty containers and chassis; or
(B) off port or intermodal rail yard property transporting cargo or empty containers or chassis that originated from or is destined to a port or intermodal
rail yard property .
Vehicle Identification Number (VIN):
Truck Make:
Truck Model Year:
Fleet ID Number (Unit #):
License Plate Number:
Manufacturer Gross Vehicle Weight Rating (GVWR):
lbs
(Refer to the tag found in the door jamb of your truck for the correct GVWR. Please attach a photograph of
this tag. NOTE: This is NOT the number registered with the DMV)
Has the truck previously received grant funding?
No
Yes
Odometer Reading:
Dash
Hub
If yes, when and where did you receive it from?
If truck has previously received funds from this program, the new grant amount will be reduced by the amount previously received.
Engine Information
Engine Model Year:
Engine Serial Number:
Fuel Type:
Is a diesel particulate filter currently installed on your truck?
No
Yes
If yes: Date of installation:
Diesel
Other:
Level of filter
Vocation and Vehicle Miles Traveled (VMT) Information
Vocation (Types of goods typically transported – Choose 1 box only)
“Goods” are defined as having the same meaning in Commercial Code section 2105, which essentially requires that:
1) The goods must be movable, and 2) The goods being moved must be part of a transaction that involves a contract for the sale of the goods.
Agricultural
Aggregates
Bulk or Break Bulk
Building/Construction
Dry Bulk Blower
Vacuum Pneumatic Trailer
Hazardous Materials
Wood/Paper Products
Heavy Equipment/Metals
Restaurant/Grocery
Poultry
Other
Estimated Percentage of Annual Vehicle Miles Traveled (VMT) in CA Trade Corridors (Total percentage cannot be over 100%)
% Bay Area
Concrete Mixer
Container
Dairy
Dump Truck
% Central Valley
% L.A./Inland Empire
% San Diego/Border Region
% Other in CA
% Out of CA
Power Take-off (PTO) Usage (if applicable)
Current PTO hour meter reading:
Does PTO operate while the main truck engine is operating?
Yes
No
II. PROPOSED NEW EQUIPMENT AND FUNDING REQUESTED
What type of project are you selecting?
New engine must be MY2013 or newer and meet emission levels of 0.20 g/bhp-hr or less of NOX (FEL and CERT values) and 0.01 g/bhp-hr or
less of PM (CERT value). (MY2010 emission standard).
Replacement Engine Emission Level
(Please check only 1 box below)
Existing Truck
Fuel Type:
MHD Engine
HHD Engine
Diesel
CNG
LNG
MY 2013 or newer
MY 2013 or newer
Class 8
(33,001 lbs or greater, HHD engine)
Class 7
(26,001 – 33,000 lbs, MHD or HHD engine)
Class 6
(19,501 – 26,000 lbs, MHD engine)
*
Funding not available
$10,000 or $
$10,000 or $
*
*
$20,000 or $
$20,000 or $
*
*
Replacement engine must be
new
Funding not available
You may request an amount lower than the maximum allowable shown to enhance the project cost-effectiveness score.
Proposed future operation within CA during Contract term (choose one):
At least 90%
100%
(Choosing 90% operation in CA during contract term may impact the competitive ranking for a project.)
Source of funds to cover costs of equipment after grant is applied:
Private (cash/loan)
Local
Other state
Federal
Did you attach one completed copy of Form A4 for each piece of equipment included in your application?
Did you initial and attach all required documents described on page 2? (see next page)
Office Use Only
App: # _______________________
Date Received:_________________
Form A4
Page 1 of 2
GOODS MOVEMENT EMISSION REDUCTION PROGRAM APPLICATION (Year 4)
FORM A4: Engine Repower – Heavy-Duty Trucks (Complete 1 Form per truck)
III. ATTACHMENTS - PLEASE INITIAL AND ATTACH THE FOLLOWING DOCUMENTS TO COMPLETE YOUR APPLICATION
____
Initial
One (1) Form A1 per applicant with original signature by authorized representative
_____
Initial
Written Estimate for New Engine and Installation
_____
Initial
Copy of current DMV Registration
_____
Initial
Copy of Existing Vehicle Title
_____
Initial
DMV Vehicle Registration Information Record
_____
Initial
One (1) mileage record showing the current odometer reading
_____
Initial
One (1) mileage record showing odometer reading from at least six (6) months ago
(Must describe all engine/truck modifications planned as part of the repower project. Include description of upgrades to such
things as exhaust systems, electronics, etc. Also, the quote must include itemized cost information of eligible expenses)
(Title is not required to be “clean” (i.e. no lienholder) at time of application, but must be clean prior to payment.)
(This report will show your previous 8 transactions at the DMV for your truck. The DMV printout may be obtained by submitting a
Request for Driver Record Information form (INF 1125) to the DMV. To find your local DMV office, please visit
http://www.dmv.ca.gov. You may also obtain and pay for the DMV printout online at: http://www.dmv.ca.gov/online/vrr.htm)
(Date on record must be within 30 days of application submittal. Acceptable documentation includes, but is not limited to,
maintenance records, Biennial Inspection of Terminals (BIT inspection), International Fuel Tax Agreement (IFTA) records, daily logs,
etc.) Documentation must clearly identify the truck by ID number, license plate, or VIN)
(Date on record must be at least six months prior to the current odometer reading record. Acceptable documentation includes, but
is not limited to, maintenance records, Biennial Inspection of Terminals (BIT inspection), International Fuel Tax Agreement (IFTA)
records, daily logs, etc.) Documentation must clearly identify the truck by ID number, license plate, or VIN.)
_____
Initial
PTO records (if applicable) showing one (1) current hour reading, and one (1) hour reading
usage from at least six (6) months ago
_____
Initial
Proof of insurance for the past 24 months
_____
Initial
Photograph of the manufacturer’s tag found in the door jamb of the truck showing VIN
and GVWR
(One (1) PTO hour record must be dated within 30 days of application submittal, and one (1) PTO hour record must be dated at
least six months prior to the current PTO hour reading record. Acceptable documentation is subject to approval by the District, but
must clearly identify the truck by ID number, license plate, or VIN.)
(Legibly printed photos only – electronic photos may be accepted at the District’s discretion)
IV. IMPORTANT NOTES
 SUBMIT completed Forms A1, A4, and all required attachments listed above to the District by the requested due date.
 DO NOT PURCHASE NEW EQUIPMENT! New equipment funded by this program can only be purchased once the
contract is signed between the equipment owner and the District. An equipment owner may pre-order new equipment
prior to contract execution and after posting of District rank list at the equipment owner’s risk.
 KEEP EXISTING TRUCK REGISTERED AND IN OPERATION! Existing equipment must maintain continuous DMV
registration and be in operation moving goods at a similar activity level to that listed in the application until the equipment
has been relinquished to a District-approved dismantler.
 STAY COMPLIANT! Fleets must remain compliant at all times with the ARB Truck and Bus Regulation without the
assistance of any grant funding requested in the application.
 FUNDING AVAILABILITY IN 2013: Funding is not anticipated to be disbursed in 2013 for eligible projects due to the
anticipated timeframe for project evaluation. Applicants are highly encouraged to plan in advance to have all new
equipment operational in 2014 for compliance purposes, and to make sure their fleet is compliant with the 2014
requirements of the ARB Truck and Bus Regulation. Retirement of existing equipment specified in this application, or the
replacement equipment being purchased, cannot be used to demonstrate compliance with the 2014 requirements.
Office Use Only
App: # _______________________
Date Received:_________________
Form A4
Page 2 of 2