San Diego County Air Pollution Control District
School Bus On-Board CNG Tank Replacement Incentive Program (TRIP)
Application #:____________
APPLICATION PACKET CHECKLIST
SCHOOL BUS ON-BOARD CNG TANK REPLACEMENT INCENTIVE PROGRAM (TRIP)
TOTAL # OF BUSES REQUESTING CNG TANK REPLACEMENTS:
TOTAL FUNDING REQUESTED: $
(no more than $20,000 per bus)
Submit a complete application packet to decrease the processing time and delay possible incentive funding. A
complete application packet includes the following items:
 One Completed Application Packet Checklist & General Application Form A (next page) and include:
 Completed Certifications Section, signed in blue ink.
 Completed Funding Disclosure, signed in blue ink.
 If applicable, Completed Third Party Information, signed in blue ink.
 Completed IRS Form W-9 (http://www.irs.gov/pub/irs-pdf/fw9.pdf)
 Completed Representations and Certifications form (submit originally signed hard copy)
(www.ftb.ca.gov/forms/2012/12_590.pdf)
 Completed CNG Tank Replacement Application (Form B) for CNG buses with tanks to be replaced.
 Dated and itemized dealer quote for the CNG tank replacement(s).
 The quote must provide a breakdown for the total cost of the CNG tanks(s) and any other eligible costs
such as labor costs associated with tank replacement.
 Documentation of existing tank expiration date for each bus.
 Copy of most recent CHP inspection for each bus.
 Approval letter from bus manufacturer confirming new tank compatibility with existing bus.
 Submit originally-signed hard copy and electronic copy of completed application (both required for
complete application) to:
San Diego County Air Pollution Control District
10124 Old Grove Rd.
San Diego, California 92131
Attn: Kathleen Keehan
Kathleen.Keehan@sdcounty.ca.gov
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rev. 4/15/11
San Diego County Air Pollution Control District
School Bus On-Board CNG Tank Replacement Incentive Program (TRIP)
FORM A
SCHOOL BUS CNG TRIP GENERAL APPLICATION
I. APPLICANT INFORMATION
1.
=
2.
Applicant Type :
School District
JPA
Private Transportation Contractor
3
Applicant Address:
4.
a. City:
b. State:
5.
a. Contact Name:
b. Contact Title:
6.
a. Contact Phone:
b. Contact Fax:
7.
Contact Email:
8.
Person with Contract Signing Authority (if different from above):
9.
School District(s) Associated with Project (if applicant is JPA or Private Contractor):
Applicant Name:
c. Zip Code:
SCHOOL DISTRICT/ORGANIZATION CERTIFICATION
I hereby certify that all information provided in this application and any attachments is true and correct to the best of my knowledge.
Printed Name of Responsible Party:
Title:
Signature of Responsible Party (Must sign in BLUE INK ONLY):
Date:
FUNDING DISCLOSURE
Have you applied for or been awarded other CNG tank replacement grants for any buses listed in this application?
Yes, fill section below and complete for each bus (attach additional sheets if necessary)
No, skip this section
Agency Applied to:
Date of Application:
Funding Amount:
Buses included in this Request (list engine VINs):
Status of Application:
Canceled
Pending
Funded
Other
THIRD PARTY INFORMATION
This section must be completed if any part or all of the application was filled out on your behalf, by a third party.
Contact Name and Title:
Business Name:
Phone Number:
Cost of Services (not eligible for funding reimbursement):
Source of Funds:
I hereby certify that all information provided in this application and any attachments is true and correct to the best of my knowledge, and
that the Air Resources Board funds may not be utilized to compensate me for my services.
Printed Name of Responsible Party:
Title:
Signature of Responsible Party (Must sign in BLUE INK ONLY):
Date:
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