0340-FM-PPEAO0083
10/2013
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
POLLUTION PREVENTION AND ENERGY ASSISTANCE OFFICE
Alternative Fuels Incentive Grant
Innovative Technology Scope of Work (Attachment D)
(Please Type or Print Legibly)
Date DEP Received:
Reviewed By:
Date DEP Reviewed:
Date DEP Approved:
1.
Project Name:
2.
Grantee Name:
3.
Primary Point of Contact:
Name:
Phone Number:
E-mail:
Secondary Point of Contact (must be provided):
Name:
Phone Number:
4.
E-mail:
Project Location:
Enter Street Address:
City:
State:
Zip Code + 4:
Check If Multiple Locations – Please list all locations on separate sheet if necessary
5.
Project Partners? (entities providing critical functions related to the completion of the project that are not a
subcontractor)
Yes
No
If yes, Please specify the name and contribution of the partner. Add more rows if needed.
A.
B.
6.
Briefly describe the project; include specific grant goals / objectives:
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7.
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Milestone and Spending Schedule (add more rows if needed). Note: Do not leave blanks. Enter “NA” if not
applicable. Enter “completed” and date completed if milestone has been completed and enter “0” under
corresponding % of grant spent if milestone related costs are not part of grant.
A.
Project Milestones (Major tasks/sub-tasks)
Please fill in all critical sub tasks, if applicable.
Identify all applicable permits
Project design
Planned
Completion Date
Enter est. % of
total grant
spent at each
milestone
1.
2.
B.
RFP or bid request released
1.
2.
C.
Contract awarded
1.
2.
D.
Equipment/fuel acquired, if applicable
1.
2.
E.
Equipment installed, if applicable, or project work
completed
1.
2.
F.
System or building testing and commissioning
1.
2.
G.
Project completed and final report
1.
2.
(Entries for % of total grant spent at each milestone must add up to 100%)
8.
100%
List project deliverables to be tracked (i.e. reports, events, information that will be sent to DEP that will clearly
demonstrate that an activity occurred). Include photos taken before, during, and after project implementation.
Add more rows if needed.
A. 30-Day Monthly Progress Reports (electronic) - due to Project Advisor by the fifth day of the following
month.
B. Final Report - due to Project Advisor within 30 days from the completion of the project.
C. One-Year Follow-Up Report following the completion of the project - due one year after completion of the
project.
D.
E.
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9.
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Disposition of Equipment
If equipment will be purchased with grant funds, please describe plans for management of the equipment at
project completion. Grantees may not dispose or convert property or equipment acquired under this grant for
purposes other than the original project without the prior written approval of the Alternate Fuels Incentive Grant
Program.
10.
Estimated Energy Performance outcomes of the project(s)
A.
Energy and Fuel Savings as a result of project deployment.
(Insert more rows if
necessary)
Specify Type
liquid fuel saved
Gals/yr
solid fuel saved
Tons/yr
gaseous fuel saved
Mcf/yr
B.
Energy and Fuel Generation as a result of project deployment (for production projects only)
(Insert more rows if
necessary)
11.
12.
Quantity
Specify Type
Quantity
liquid fuel generated
Gals/yr
solid fuel generated
Tons/yr
gaseous fuel generated
Mcf/yr
Estimated investment in economy from project budget. Enter “NA” if not applicable. Total of 11A and B should
equal the total project cost.
A.
Dollars to be spent on goods (purchase of materials and equipment) $
B.
Dollars to be spent on services (construction, design, research, planning, trainers etc.) $
Economic development benefits. Enter “NA” if not applicable.
A.
Savings to Pennsylvania consumers ($/yr)
B.
Value of contracts with PA suppliers or contractors. ($/yr)
C.
Energy Saving Equipment or Energy Generating Components (highlight all that apply): manufactured (for
manufacturing projects only), sold or deployed in PA.
(Insert more rows if necessary)
Specify Type and who manufactured
Units/components manufactured
Units/components sold
Units/components deployed
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Quantity
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13.
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Environmental Benefit Data: If applicable, provide the answers to the following statements in the format of a
table. Add additional rows if necessary. Fill in all blanks. Enter NA if not applicable.
(Insert more rows if necessary)
Specify Type
Quantity
Air pollutant reduced
PM
lbs/yr
Air pollutant reduced
HC
lbs/yr
Air pollutant reduced
CO
lbs/yr
Air pollutant reduced
NOX
lbs/yr
Air pollutant reduced
SO2
lbs/yr
Air pollutant reduced
CO2
lbs/yr
Number of PA Citizens directly educated
14.
persons/yr
Estimated Job creation and retention Measures
Jobs directly created – number of temporary and permanent jobs created by grant award funds and for
how long (# years). Add more rows if needed.
A.
List Job (Full-time/part-time,
temporary/permanent)
Type (Describe)
Jobs directly retained – number of jobs saved and supported by grant award funds and for how long
(# years). Add more rows if needed.
B.
List Job (Full-time/part-time,
temporary/permanent)
15.
Duration (# years)
Type (Describe)
Duration (# years)
Permits required to complete this project (also enter under each respective milestone/subtask in Item 7). Enter
NA if not applicable. Add more rows if needed.
Date obtained or
to be obtained
Type of Permit
A.
B.
C.
16.
Are any property easements or landowner agreements required?
No
Yes – Document(s) provided to Department
Yes - mail Document(s) later
If Yes – Document(s) were provided to Department, then please identify landowner(s)
If agreement will be reached at a later date, then please submit landowner agreements at that time.
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17.
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Will subcontractors be used?
Yes
No
If yes, specify the name of the subcontractor and the information requested below including the process by
which they will be selected (e.g. bid, sole source, direct award, etc.). If not yet selected, under “Subcontractor”
enter “TDB – will provide name and Federal ID # to DEP for approval prior to start of work", and describe the
selection process. Add more rows if needed.
Subcontractor
Fed ID
Process Selected
A.
B.
C.
D.
18.
Project Budget:
Grant Amount:
$
Match Amount:
$
Total Project Costs:
$
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