R-10429City Council Meeting: 10/13/2009
Santa Monica, California
RESOLUTION NUMBER 10429 (CCS)
(City Council Series)
A RESOLUTION OF THE CITY COUNCIL
OF THE CITY OF SANTA MONICA AUTHORIZING THE CITY MANAGER TO FILE.
THE FY2010-2012 SHORT RANGE TRANSIT PLAN; AND TO SUBMIT GRANT
APPLICATIONS, TO EXECUTE GRANT AGREEMENTS IN FURTHERANCE OFTHE
SHORT RANGE TRANSIT PLAN.
NOW, THEREFORE, THE-CITY COUNCIL OF THE CITY OF SANTA MONICA
DOES RESOLVE AS FOLLOWS;
SECTION 1. The City Council of the City of Santa Monica hereby authorizes the
City Manager to file the FY 2010-2012 Short-Range Transit Plan ("SRTP") with the Los.
Angeles County Metropolitan Transportation Authority (°Mefro'~.
SECTION 2. The City Council. of the City of Santa Monica also authorizes the
City Manager to file grant applications and to execute grant agreements to accept
federal, state, regional and local transit assistance in accordance with the SRTP,
including, but not limited. to, the Federal Transit Administration ("FTA"), Metro, South
Coast Air Quality Management District ("SCAQMD"), State DepacSrnent of Homeland
Security {"Homeland Security"), and the California Department of Transportation
("Caftrans"), among others. The City Manager is also authorized to enter into grant
1
agreements with subgrantees for the pass-through of grant funds in accordance with the
terms of the applicable grant and the SRTP
SECTION 3. The City Clerk shall certify to the adoption of this Resolution, and
thenceforth and thereafter the same shall be in full force and effect.
APPROVED AS TO FORM:
Adopted and approved this 13th day of October, 2009.
~~
Ken Genser, ayor
I, Maria Stewart, City Clerk of the City of Santa Monica, do hereby certify that the
foregoing Resolution No. 10429 (CCS) was duly adopted at a meeting of the Santa
Monica City Council held on the 13th day of October, 2009, by the following vote:
Ayes: Council members: Bloom, Holbrook, McKeown
Mayor Genser
Noes: Council members: None
Abstain: Council members: None
Absent: Council members: Davis, Shriver
Mayor Pro Tem O'Connor
ATTEST:
~i ..~-
Maria Stewart, City Clerk
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
FORM A-1 -GENERAL PROJECT INFORMATION
APPLICATION
All information in Form A-1 constitutes all required information with the exception of the
supplemental forms specific to the project equipment.
Applicant Name: Santa Monica's Big Blue Bus
Address: 1660 7 Street, Santa Monica, CA 90401
Phone #: 310.458.1975 x2296 Cell #:
Please use this section to summarize the scope of your project proposal. Please
indicate, by category, the total funding request, number of units, and the type of project
(i.e. New Purchase, Repower, Retrofit, TRU, etc). Please keep in mind that the total
percentage of eligible funding amount varies from one project category to another, for
more information refer to the Carl Moyer Guidelines available at
htto:/lwww.arb.ca.gov/msorog/mover/2008ouideline updates htm
Funding Request
Category Amount Requested Number of Units Repower_ New_ etc.
On-Road $ 82,400/unit 37 Units Re ower
On-Road $ Units T e
On-Road $ Units T e
Are on-road trucks 1989 or older? Yes No XX
What is your fleet size? 203. vehicles
Off-Road $ Units T pe
Off-Road $ Units T pe
Off-Road $ Units T pe
What is your fleet size in horsepower?
Marine $ Units T e
Marine $ Units T pe
Locos $ Units T e
Locos $ Units T pe
Locos $ Units T pe
Other
$
Units
T pe
$ Units Type
Total Funds Requested $ 3,048,800
General Project Information Application Page 1 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
All Sections of Form A-1 must be submitted for an application to be deemed complete.
If information does not pertain to your project, please write "NA" on the form and sign it.
In addition, supplemental forms are required for each piece of requested equipment.
I. Applicant Information
Company name/ Organization name/ Individual name:
Santa Monica's Big Blue Bus
Business address (Mailing address): Street: 1660 7t Street
City: Santa Monica State: CA Zip code: 90401
Contact name and title: Enny Chung, Senior Administrative Analyst
E-mail: ennv.chungro-~smgov.net
Phone: (310) 458-1975 x2296 Fax: (310) 395-5460
Person with contract signing authority (if different from above): P. Lamont Ewell, City
Manager
I hereby certify that all information provided in this application and any
attachments are true and correct.
Printed Name of Responsible Party:
Enny Chung Title:
Senior Administrative Analyst
Signature of Responsible Party: Date:
Complete this section if application was prepared by another person
I have completed the application. in whole or in part. on behalf ~f the annlirant
Printed Name: Title:
Signature: Date:
Amount Being Paid for Application Completion Source of funding to 3rd party:
in Whole or Part:
II. FUNDING INFORMATION
Total Number of Equipment Included in Project:
37
Total Number of Engines Included in Project:
37
Total Amount of Funding Requested: Total Applicant Co-Funding Amount (if any):
$3,048,800 $
General Project Information Application Page 2 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOVER PROGRAM (FY 08/09)
III. General Project Information
There are three types of emission reduction projects:
New Purchase - Purchasing a new vehicle or piece of equipment with an engine that is .
cleaner than the currerit year standard.
Repower -Replacing an existing engine with a new reduced-emission engine.
Retrofit -Installing an ARB-verified emission control system on an in-use engine.
IMPORTANT REMINDER: Only projects that are demonstrated to be surplus to
California Air Resources Board (ARB) regulations are eligible for Carl Moyer Program
(CMP) funding. Please ensure your proposed project is eligible prior to submitting an
application.
Check the appropriate box(es) below for each type of project and indicate the total
number of equipment/engines included in your project.
B. Off-Road Diesel &LSI Equipment
Diesel Fleet Size (Total hp): ^ Small < 2,500 ^ Medium 2,501-5,000 ^ Large > 5,000
LSI Fleet Size (No. of Units): ^ Small < 4 ^ Medium 4 to 25 ^ Large > 25
NOTE: Only new purchases or equipment retrofits for fleets with no greater than -three (3) pieces of off-road
large spark-ignition (LSI) engine-equipped forklifts, sweepers/scrubbers, industrial tow tractors or airport ground
support equipment are eligible for CMP funding. Pre-1990 agricultural forklifts, aerial lifts and construction or
mining equipment not subject to the LSI regulation are eligible. Note that this is the last year of eligibility for
medium and large fleets.
Equipment Replacement -Total piedes of equipment:
A supplemental application (Form B-1) must be completed for each piece of new equipment
^Repower Only- Total engines to be repowered:
A supplemental application (Form B-2) must be completed for each engine reower
^Repower with Retrofit -Total engines to be repowered/retrofit:
A supplemental application (Form B-2) must be completed for each engine repower
^Retrofit Only -Total engines to be retrofit:
A supplemental application (Form B-3) must be completed for each retrofit
^Large Spark Ignition (LSI) Equipment or Engine -Total equipment units or engines in the
project: A supplemental application (Form B-1, B-2 or B-3) must be completed for
each unit.
General Project Information Application Page 3 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
NOTE: For On-Road purchase and repower projects, only alternative fuel vehicles and engines are eligible for
funding, with the exception of emergency vehicles and equipment. On-road heavy-duty diesel vehicles/engines
are eligible to receive CMP funds for retrofits as long as the project is "surplus" to ARB regulations.
NOTE: All on-road repower projects must include installation of the highest level ARB-verified retrofit device.
Repower projects are not disqualified from participation in the Carl Moyer Program if retrofit devices are not
available, technically infeasible or unsafe. If installation of a retrofit device is infeasible or unsafe you MUST
provide documentation from the retrofit device manufacturer stating the reason(s) that the device is infeasible or
unsafe.
^ New Purchase -Total pieces of equipment:
A supplemental application (Form C-1) must be completed for each piece of new equipment
XX Repower -Total engines to be repowered: 37
A supplemental application (Form C-2) must be completed for each engine repower
^ Retrofit Only -Total engines to be retrofit:
A supplemental application (Form C-3) must be completed for each retrofit
^ Auxiliary Power Unit (APU) -Total units:
A supplemental application (Form F) must be completed for each APU
D. Marine Vessels
^ Repower -Total engines to be repowered:
A supplemental application (Form D-1) must be completed for each engine repower
^ Retrofit Only -Total engines to be retrofit:
A supplemental application (Form D-2) must be completed for each retrofit
E. Locomotives
Note: All locomotive purchase and repower projects (except alternative technology switchers) MUST include
purchase and installation of an AESS ILD device to reduce unnecessary engine idling if the locomotive is not
already equipped with such a device and AESS installation is technically feasible. All ILDs must comply with
applicable durability and warranty requirements.
^ New Purchase -Total number of locomotives:
A supplemental application (Form E-1) must be completed for each new locomotive
^ Repower -Total engines to be repowered:
A supplemental application (Form E-2) must be completed for each engine repower
^ Engine Remanufacture Kit-Total engine remanufacture kits:
A supplemental application (Form E-2) must be completed for each remanufacture
^ Idle Limiting Device (ILD) Only -Total ILDs to be installed:
A supplemental application (Form E-1) must be completed for each ILD
General Project Information Application Page 4 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
F. Transport Refrigeration Units (TRU)
^ Ultra Low Emission TRU Project -Total number of units:
A supplemental application (Form F) must be completed for each new unit
^ Zero-Emission TRU Project -Total number of units:
A supplemental application (Form F) must be completed for each engine repower
IV. FUNDING DISCLOSURE
Have any engines or vehicles listed in this application been awarded funding from the Air
Resources Board or another public agency or are any being considered for funding?
^ Yes
XX No
If "yes", complete the following for each engine or vehicle:
Agency applied to:
Date/Number of Agency Solicitation:
Total Funding Amount Requested or Awarded:
Amount per Unit Requested or Awarded:
Status:
Do you plan to claim a tax credit or deduction for the project vehicle?
^ Yes
^ No
If "yes", please indicate the estimated tax credit amount to be claimed per vehicle: -
General Project Information Application Page 5 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
Application Statement -Please Read and Sign
All information provided in this application will be used by AQMD staff to evaluate the eligibility of this
application to receive program funds. AQMD staff reserves the right to request additional information and
can deny the application if such requested information is not provided by the requested deadline.
Incomplete or illegible applications will be returned to applicant or vendor, without evaluation. An
incomplete application is an application that is missing information critical to the evaluation of the project.
• I certify to the best of my knowledge that the information contained in this application is true and
accurate.
e I understand that, if awarded funding under the CMP, development and submittal of a detailed
work statement, with deliverables and schedule is a requirement of the contracting process.
• I understand that it is my responsibility to ensure that all technologies are either verified or certified
by the California Air Resources Board (GARB) to reduce NOx and/or PM pollutants. GARB
Verification Letters and/or Executive Orders are attached, as applicable.
e I understand that for repower projects, I am required to install the highest level available verified
diesel emission control device (VDECS), and that the costs of this device and associated
installation are a CMP eligible expense. These costs may be included in the project grant request
up to the maximum cost-effectiveness limit.
e I understand that there may be conditions placed upon receiving a grant and agree to refund the
grant (or pro-rated portion thereofl if it is found that at any time I do not meet those conditions and
if directed by the AQMD in accordance with the contract agreement.
I understand that, for this equipment, I will be prohibited from applying for any other form of
emission reduction credits for Moyer-funded vehicles/engines, including: Emission Reduction
Credit (ERG); Mobile Source Emission Reduction Credit (MSERC) and/or Certificate of Advanced
Placement (CAP), for all time, from the AQMD, GARB or any other Air Quality Management or Air
Pollution Control District.
e The proposed project has not been funded and is not being consitlered for Carl Moyer Program
funds by another air district, GARB, or any other public agency.
e In the event that the vehicle(s)/equipment do not complete the minimum term of any agreement
eventually reached from this application, I agree to ensure the equivalent project emissions
reductions, or to return grant funds to the AQMD as required by the contract.
s I understand that all on-road engines in my fleet that are eligible for a low NOx software upgrade
(reflash) must be reflashed within 6Q days of receipt of an award payment. I may self-certify that
the reflash has been performed by submitting receipt of reflash completed or a picture of the "Low
NOx Refaash Label: from the reflashed engine to the district.
General Project Information Application Page 6 of 22 Form A-1
~"
United State Environmental Protection Agency
Washington, DC 20460
Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that it and the principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) Have not within a three year period preceding this proposal been convicted of or had a civil
judgement rendered against them or commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or
contract under a public transaction: violation of Federal or State antitrust statute or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property:
(c) Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of
this certification; and
(d) Have not within athree-year period preceding this application/proposal had one or more public
transactions (Federal, State, or local) terminated for cause or default.
I understand that a false statement on this certification may be grounds for rejection of this proposal or
termination of the award. In addition, under 18 USC Sec. 1001, a false statement may result in a fine
of up to $10,000 or imprisonment for up to 5 years, or both.
Typed N~ & Title of Authorized
of
Date
^ 1 am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
General Project Information Application Page 18 of 22 - Form A-1
CAMPAIGN CONTRIBUTIONS DISCLOSURE
California law prohibits a party, or an agent, from making campaign contributions to AQMD Governing
Board Members or members/alternates of the Mobile Source Pollution Reduction Committee (MSRC)
of $250 or more while their contract or permit is pending before the AQMD; and further prohibits a
campaign contribution from being made for three (3) months following the date of the final decision by
the Governing Board or the MSRC on a donor's contract or permit. Gov't- Code §84308(d). For
purposes of reaching the $250 limit, the campaign contributions of the bidder or contractor ,plus
contributions by its parents_ affiliates and related companies of the contractor or bidder are added
In addition, Board Members or members/alternates of the MSRC must abstain from voting on a
contract or permit if they have received a campaign contribution from a party or participant to the
proceeding, or agent, totaling $250 or more in the 12-month peridd prior to the consideration of the
item by the Governing Board or the MSRC. -Gov't Code §84308(c). When abstaining, the Board
Member or members/alternates of the MSRC must announce the source of the campaign contribution
on the record. /d. The requirement to abstain is triggered by campaign contributions of $250 or more
in total contributions of the bidder or contractor, plus any of its parent, subsidiarv. or affiliated
companies. 2 C.C.R. §18438.5.
In accordance with California law, bidders and contracting parties are required to disclose, at the time
the application is filed, information relating to any campaign contributions made to Board Members or
members/alternates of the MSRC, including: the name of the party making the contribution (which
includes any parent, subsidiary or otherwise related business entity, as defined below), the amount of
the contribution, and the date the contribution was made. 2 C.C.R. §18438.8(b).
The list of current AQMD Governing Board Members can. be found at the AQMD website
(www.a md. ov . The list of current MSRC members/alternates can be found at the MSRC website
(~:_ www.c eantransportationfundina.ora).
SECTION I. Please complete Section I.
Contractor: RFP #
List any parent, subsidiaries, or otherwise affiliated business entities of Contractor:
(See definition be/ow).
SECTION II
Has contractor and/or parent, subsidiary, or affiliated company, or agent thereof, made a campaign
contribution(s) totaling $250 or more in the aggregate to a current member of the South Coast Air
Quality Management Governing Board or members/alternates of the MSRC in the 12 months
preceding the date of execution of this disclosure?
^ Yes ~No If YES, complete Section 11 below and then sign and date the form
If NO, sign and date below. Include this form with your submittal.
General Project Information Application Page 19 of 22 Form A-1
Campaign Contributions Disclosure, continued:
Name of Contributor
Governing Board Member or MSRC Member/Alternate .Amount of Contribution Date of Contribution
Name of Contributor
Governing Board Member or MSRC Member/Alternate Amount of Contribution Date of Contribution
Name of Contributor
Governing Board Member or MSRC Member/Alternate Amount of Contribution Date of Contribution
Name of Contributor
Governing Board Member or MSRC Member/Alternate Amount of Contribution Date of Contribution
Name of Contributor
Governing Board Member or MSRC Member/alternate Amount of Contribution
I decl e f egoing isc sur o be true and correct.
.-
Ti e' City Manager
Date: `~'~~~-~- /9 x-009
Date of Contribution
General Project Information Application Page 20 of 22 Form A-1
DEFINITIONS
Parent, Subsidiary, or Otherwise Related Business Entity.
(1) Parent subsidiary. A parent subsidiary relationship exists when one
corporation directly or indirectly owns shares possessing more than 50
percent of the voting power of another corporation.
(2) Otherwise related business entity. Business entities, including corporations,
partnerships, joint ventures and any other organizations and enterprises
operated for profit, which do not have a parent subsidiary relationship are
otherwise related if any one of the following three tests is met:
(A) One business entity has a controlling ownership interest in the
other business entity.
(B) There is shared management and control between the entities. In
determining whether there is shared management and contro%
consideration should be given to the following factors:
(i) The same person or substantially the same person owns
and manages the two entities;
(ii) There are common or commingled funds or assets;
(iii) The business entities share the use of the same offices
or employees, or otherwise share activities, resources or
personnel on a regular basis;
(iv) There is otherwise a regular and close working
relationship between the entities; or
(C) A controlling owner (50% or greater interest as a shareholder or as
a general partner) in one entity also is a controlling owner in the
other entity.
2 Cal. Code of Regs., §18703.1(d).
General Project Information Application Page 21 of 22 Form A-1
AQMD Use Only: App. # Project
' a ..~
Form C-2 - ON-ROAD HEAVY-DUTY VEHICLES
Repower
For On-Road vehicle projects, only alternative fuel vehicles and engines are eligible for
funding, with the single exception of emergency vehicles and equipment.
Please complete one form for each piece of equipment. For multiple unit requests, you may
submit a spreadsheet that provides all requested information below, in the order presented
below.
Company name/ Organization name/Individual name:
Santa Monica's Big Blue Bus
Equipment Identifier (Company ID or Unit #): 4001
Is the vehicle location address the same as the applicant address? XX Yes ^ No, (please
provide vehicle address below)
Street Address:
City:
Zip Code:
I. EXISTING VEHICLE INFORMATION
VehlCle type (Solid Waste Collection Vehicle, Stop-and-Go Street Sweeper, Urban Transit Bus, School Bus,
Other Medium-Heavy Duty Vehicle (GVWR 14,001-33,000 Ibs), Other Heavy-Heavy Duty Vehicle (GVWR >33,000
Ibs), Other Transit Vehicle): Urban Transit BUS
PfOjeCt Life: 6 years. Equipment must operate for this full life; this life is equivalent to the contract and the
reporting term.
Vehicle Identification Number (VIN): 1N90402372A140006
Vehicle License Plate: 1145999
Vehicle Make: NABI Vehicle GVWR: 39,630 Ibs
Vehicle Model: TOP BUS 40LFW-23 Is this a public fleet vehicle? XX Yes ^ No
Vehicle Model Year: 2002 Registered Owner: City of Santa Monica
Department of Transportation Number (if interstate):
California Highway Patrol CA Number (if applicable):
Projected Year of Repower Completion: 2010
On Road HD -Repower Page 1 of 4 Form C-2
II. FLEET RULE STATUS
ARB Rule Applicability (Check One): NOTE: The ARB rules listed below severely limit, and in
some cases eliminate, funding opportunities for certain vehicle types. Please confirm your project
provides emission reductions that are surplus to ARB regulatory requirements in order to ensure
eligibility.
XX Fleet Rule for Transit Agencies (Urban Buses & Transit Fleet Vehicles)
^ SWCV Rule (Solid Waste Collection Vehicles, Excluding Transfer Trucks)
^ Fleet Rule for Public Agencies & Utilities (Municipal & Utility Vehicles)
^ Port Truck Regulation (Port & Drayage Trucks)
^ In-Use HDD Fueled Vehicles (All diesel or alternative diesel- fueled vehicles with a
GVWR > 14,000 Ibs operating in CA)
^ None, project is exempt from CARB Rules (supporting documentation validating
exemption from any CARB rule is attached)
Is supporting documentation demonstrating compliance with the applicable ARB rule
in this application? XX Yes ^ No
(Applications submitted without supporting documentation that demonstrates an applicant's current fleet
compliance status will be deemed incomplete).
III. ACTIVITY INFORMATION
Please provide projected annual usage for the new equipment over the proposed life of the
project. This projection should be based on actual usage data for the baseline, or existing,
equipment.
Applicants requesting evaluation based on fuel consumption MUST provide both mileage and
fuel records from the past 24 months. Supporting documentation may be in the form of
maintenance records, fuel receipts, logs, or other paperwork for each piece of baseline
equipment covering at least the last 24 months.
No such documentation is required for project evaluations based solely on mileage.
Total Annual Miles Traveled: 34,617 or Gallons of Fuel Used:
Percent Operation within CA: 100% Percent Operation within District: 100%
IV. BASELINE ENGINE INFORMATION
Baseline Main Engine
Fuel Type: LNG Engine Year: 2002
Engine Make: Engine Serial No.: 0480039076
Engine Model: Engine Family:
On Road HD - Repower Page 2 of 4 Form C-2
V. NEW REDUCED-EMISSION ENGINE INFORMATION
New Reduced-Emission Main Engine
Fuel Type: LNG Engine Year: 2010
Engine Make: Cummins Engine Family: 8CEXH0540LBD
Engine Model`. ISL G 280
Will a retrofit be added to the new main engine? ^ Yes XX No (if yes, fill out Section V)
ARB Certification Executive Order (EO) Number: A-021-0457-1
NOTE: The proposed engine for the project must be consistent with the Intended Service Class per the
EO (MHD Intended Service Class engines cannot be used for projects which have the HHD vehicle
classifications). Applicant must ATTACH a copy of the referenced Executive Order with the application.
VI. RETROFIT INFORMATION (for each new engine)
NOTE: You MUST attach a copy of the ARB Executive Order for the retrofit device and indicate (circle) on the
Executive Order Attachment the engine family name for the engine on which the device will be installed.
NOTE: All on-road repower projects must include installation of the highest level ARB-verified retrofit device if one
is available. Repower projects are not disqualified from participation in the Carl Moyer Program if retrofit devices
are not available, technically infeasible or unsafe. If installation of a retrofit device is infeasible or unsafe you MUST
provide documentation from the retrofit device manufacturer stating the reason(s) that the device is infeasible or
unsafe.
Retrofit Make: Verified NOx Reduction:
Retrofit Device Model: Verified PM Reduction:
Retrofit Family Name: Verified ROG Reduction:
Verification Level
VII. FUNDING INFORMATION
Note: You MUST attach a written estimate from the equipment vendor documenting the cost of the new equipment;
this quote must be obtained within 90 days prior to the closing date of the Program Announcement. .
New Engine Cost: $103,000 (including tax)
New Engine Installation Cost:
Engine Core Charge (optional):
Applicant Grant Request: $82,400
New Engine Vendor: Cummins Cal Pacific
On Road HD -Repower Page 3 of 4 Form C-2
New Engine Installer: Cummins Cal Pacific
RETROFIT SYSTEM COST (include if a retrofit device is proposed for this project)
Retrofit Device Cost (including tax): $
Note: You MUST attach a written estimate from the equipment vendor documenting the cost of the device; this
quote must be obtained within 90 days prior to the closing date of the Program Announcement.
Retrofit Device Installation Cost:
Retrofit Device Maintenance Cost:
Applicant Grant Request: $
Retrofit Device Vendor and Installer:
On Road HD - Repower Page 4 of 4 Form C-2
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08/09)
s I have the legal authority to apply for grant funding for the entity described in this application.
• Disclosure of that value of any current financial incentive that directly reduces the project price,
including tax credits or deductions, grants, or other public financial assistance for the same engine
is required. To avoid double counting of incentives, all tax credits or deductions, grants, or other
public financial assistance must be deducted from the CMP request.
• I understand that third party contracts are not permitted. A third party may, however complete an
application on an owner's behalf. Third parties are required to list how much compensation, if any,
they are receiving to prepare the application(s), and to certify that no CMP funds are being used.
for this compensation. (see below)
• I understand that additional project information must be submitted to finalize a contract. This
information may be found under Section II: Work Statements/Schedule of Deliverables in the PA.
• I understand that all vehicles; engines or equipment funded by this program must be operational
within eighteen (18) months of contract execution, or by May 31, 2010, whichever is earlier.
• I have initialed this bullet to indicate that there are no potential conflicts of interest with other
clients affected by actions performed by the firm on behalf of the AQMD. If this bullet is not
initialed, I have attached a descripti6' this application of the potential conflict of interest, which
will be screened on a case-b cas by the AQMD District Counsel's Office. There is no
potential conflict of interest: (Please Initial if applicable, otherwise attach separate
sheet describing the potentia co ctj,
`~~-y.~u ~- /~ a~~ ~
Date
P. Lamont Ewell
Applicant's Name (please print)
Citv Manager
Title
---'-z~TTEST
MARIA STEWART
City Clerk
APPROVED AS TO FORM
1 ~t , Jl~%~~,~~
MARS f JONES //M TRIE
City ~tCorne~
General Project Information Application Page 7 of 22 Form A-1
SOUTH COAST AIR QUALITY MANAGEMENT DISTRICT
YEAR 11 CARL MOYER PROGRAM (FY 08109)
Please initial each section.
(See PA#2009-06 for additional information and requirements):
The purchase of this low-emission technology is NOT required by any local, state, and/or
federal rule_or regulation (with the exception_ of Agricultural Assistance Program_projects)_
The definitions of qualifying projects are described in PA #2009-06. These definitions
have been_reviewed_and this_applidation is consistent_with those definitions.
- - --------------
The vehicle/engine will be used within the SCAQMD boundaries (with the emission
reduction system operating) for at least the projected usage shown in this application,
and no less than 75 percent_of the time__ _
All project applicants must submit documentation that supports the activity claimed in the
application (i.e., fuel receipts, mileage logs and/or hour-meter readings covering the last
two_years)___This documentation is attached.
The grant contract language can not be modified withdut the written consent of all
parties._ I_ have reviewed arid_accepted the sample contact language_ __ __ __
I understand that. an IRS Form 1099 may be issued to me for incentive funds received
under the Moyer Program. I understand that it is my responsibility to determine the tax
liability_associated withparticipating in the Moyer Program_ __________
Iunderstand that aSCAQMD-funded Global Positioning System (GPS) unit will be
installed on vehicles/equipment not operating within SCAQMD boundaries full time. I will
submit data as requested and otherwise cooperate with all data reporting requirements. I
also understand that the additional cost of the GPS unit will be added to the project cost
when calculating cost-effectiveness, though the SCAQMD will pay for this system
directly----------------- -
I understand that the SCAQMD has the right to conduct unannounced inspections for the
full project life to ensure the project equipment is fully operational at the activity level
committed to bar the contract---- -------- -------- -------- ---------- -------- - ------- --- --
I understand that all emission reductions resulting from funded projects will be retired.
To avoid double counting of emission reductions, project vehicles and/or equipment may
not receive funding from any other government grant program that is designed to reduce
mobile source emissions.
I understand that a tamper proof, non-resettable digital hour meter/odometer must be
installed on all vehicles/equipment and that the digital hour meter/odometer will record
the hours/miles accumulated wdhln the SCAQMD boundanes Thls cost Is my
responsibility_______ __
I understand that any tax credits claimed must be deducted from the CMP request.
Please check one:
~do not plan to claim a tax credit or deduction for costs funded by the CMP.
I do plan to claim a tax credit or deduction for costs funded by the CMP.
If so, please indicate amount here: $
I plan to claim a tax credit or deduction only for the portion of incremental costs not
____funded by the CMP._ If so,_please indicate_amount here_ $
General Project Information Application Page 8 of 22 Form A-1
South Coast
Air Quality Management District
21865 Copley Drive, Diamond Bar, CA 91765-4178
(909) 396-2000 • www.aclmd.gov
Business Information Request
Dear SCAQMD Contractor/Supplier:
The South Coast Air Quality Management District (SCAQMD) is committed to ensuring that
our contractorlsupplier records are current and accurate. If your firm is selected for award of
a purchase order or contract, it is imperative that the information requested herein be
supplied in a .timely manner to facilitate payment of invoices. In order to process your
payments, we need the enclosed information regarding your account. Please review and
complete the information identified on the following pages, complete the enclosed W-9
form, remember to sign both documents for our files, and return them as soon as
possible to the address below:
Attention: Accounts Payable, Accounting Department
South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, CA 91765-4178
If you do not return this. information, we will not be able to establish you as a vendor. This will
delay any payments and would still necessitate your submittal of the enclosed information to
our Accounting department before payment could be initiated. Completion of this document
grid enclosed forms would ensure that your payments are processed timely and accurately.
If you have any questions or need assistance in completing this information, please
contact Accounting at (909) 396-3777. We appreciate your cooperation in completing
this necessary information.
Sincerely,
Patrick H. Pearce
Chief Financial Officer
DH:LU:CWam
Enclosures:- Business Information Request
Disadvantaged Business Certification
W-9
Federal Contract Debarment Certification
General Project Information Application Page 9 of 22 - Form A-1
BUSINESS INFORMATION REQUEST
Business Name City of Santa Monica's Big Blue Bus
Division of: N/A
Subsidiary of:
WebsiteAddress www.blgblUebUS.COm
Type of Business Transit Agency
REMITTING ADDRESS INFORMATION
Address 1660 7th Street
citylrown Santa Monica
State/Province California zip 9401
Phone (310) 458-.1975 Ext Fax (310) 395-5460
Contact Title
E-mail Address
.Payment Name if
Different
All invoices must reference the corresponding Purchase Order Number(s)/Contract
Number(s) if applicable and mailed to:
Attention: Accounts Payable, Accounting Department
South Coast Air Quality Management District
21865 Copley Drive
Diamond Bar, CA 91765-4178
General Project Information Application Page 10 of 22 Form A-1
DISADVANTAGED BUSINESS CERTIFICATION
Federal guidance for utilization of disadvantaged business enterprises allows a vendor to be deemed a small business enterprise (SBE),
minority business enterprise (MBE) or women business enterprise (WBE) if it meets the criteria below,
• is certified by the Small Business Administration or ,
• is certified by a state or federal agency or
• is an independent MBE(s) or WBE(s) business concern which is at least 51 percent owned and controlled by minority
group member(s) who are citizens of the United States.
Following state guidance, a vendor may be deemed a disabled veteran business enterprise (DVBE) if it meets the following:
• is an independent business concern which is at least 51 percent owned and controlled by disabled veteran(s), and the
home office is located in the U.S.
Statements of certification:
As a prime contractor to the SCAQMD, - (name of business) will engage in good faith
efforts to achieve the fair share in accordance with 40 CFR Section 31.36(e), and will follow the six affirmative steps
listed below for contracts or purchase orders funded to whole or in cart by federal grants and contracts
1. Place qualified SBEs, MBEs, and WBEs on solicitation lists.
2. Assure that SBEs, MBEs, and WBEs are solicited whenever possible.
3. When economically feasible, divide total requirements into small tasks or quantities to permit greater
participation by SBEs, MBEs, and WBEs.
4. Establish delivery schedules, if possible, to encourage participation by SBEs, MBEs, and WBEs.
5. Use services of Small Business Administration, Minority Business Development Agency of the Department of
Commerce, and/or any agency authorized as a clearinghouse for SBEs, MBEs, and WBEs.
6. If subcontracts are to be let, take the above affirmative steps.
Self-Certification Verification:
Check all that. apply:
^ Small business enterprise
^ Local business
^ Minority-owned business enterprise
^ Women-owned business enterprise
^ Disabled veteran-owned business enterprise
Percent. of ownership:
Name of Qualifying Owner(s):
I, the undersigned, hereby declare that to the best of my knowledge the above information is accurate. Upon penalty of
perjury, 1 certify information submitted is factual.
NAME
TITLE
TELEPHONE NUMBER
DATE
General Project Information Application Page 11 of 22 Form A-1
Definitions For Self-Certification Verification
Disabled Veteran-Owned Business Enterprise means a business that meets all of the fallowing criteria:
• is a sole proprietorship or partnership of which is at least 51 percent owned by one or more disabled
veterans, or in the case of any business whose stock is publicly held, at least 51 percent of the stock is
owned by one or more disabled veterans; a subsidiary which is wholly owned by a parent corporation but
only if at least 51 percent of the voting stock of the parent corporation is owned by one or more disabled
veterans; or a joint Venture in which at least 51 percent of the joint venture's management and control and
earnings are held by one or more disabled veterans.
• the management and control of the daily business operations are by one or more disabled veterans. The
disabled veterans who exercise management and control are not required to be the same disabled
veterans as the owners of the business.
• is a sole proprietorship, corporation, partnership, or joint venture with its primary headquarters office
located in the United States and which is not a branch or subsidiary of a foreign corporation; firm, or other
foreign-based business.,
Joint Venture means that one party to the joint venture is a MBENVBE/DVBE and owns at least 51 percent of the joint
venture. In the case of a joint venture formed for a single project this means that MBENVBE/DVBE will receive at least 51
percent of the project dollars.
Local Business means a business that meets all of the following criteria:
• has an ongoing business within the boundary of the SCAQMD at the time of bid application.
• performs 90 percent of the work within SCAOMD's jurisdiction.
Minority-Owned Business Enterprise means a business that meets all of the following criteria
is at least 51 percent owned by one or more minority persons or in the case of any business whose stock
is publicly held, at least 51 percent of the stock is owned by one or more minority persons.
is a business whose management and daily business operations are controlled or owned by one or more
minority person.
is a business which is a sole proprietorship, corporation, partnership, joint venture, an association, or a
cooperative with its primary headquarters office located in the United States, which is not a branch or
subsidiary of a foreign corporation, foreign firm, or other foreign business.
"Minority" person means a Black American, Hispanic American, Native American (including American Indian, Eskimo,. Aleut,
and Native Hawaiian), Asian-Indian American (including a person whose origins are from India, Pakistan, or Bangladesh),
Asian-Pacific American (including a person whose origins are from Japan, China, the Philippines, Vietnam, Korea, Samoa,
Guam, the United States Trust Territories of the Pacific, Northern Marianas, Laos, Cambodia, or Taiwan).
Small Business Enterprise means a business that meets the following criteria:
a. 1) an independently owned and operated business; 2) not dominant in its field of operation; 3) together with
affiliates is either.
• A service, construction, or non-manufacturer with 100 or fewer employees, and average annual
gross receipts of ten million dollars ($10,000,000) or less over the previous three years, or
• A manufacturer with 100 or fewer employees.
b. Manufacturer means a business that is both of the following:
1) Primarily engaged in the chemical or mechanical transformation of raw materials or processed substances
into new products
2) Classified between Codes 2000 to 3999, inclusive, of the Standard Industrial Classification (SIC) Manual
published by the United States Office of Management and Budget, 1987 edition.
General Project Information Application Page 12 of 22 Form A-1
Women-Owned Business Enterprise means a business that meets all of the following criteria:
is at least 51 percent owned by one or morewomen or in the case of any business whose stock is publicly
held, at least 51 percent of the stock is owned by one or more women.
is a business whose management and daily business operations are controlled or owned by one or more
women.
is a business which is a sole proprietorship, corporation, partnership, or a joint venture, with its primary
headquarters office located in the United States, which is not a branch or subsidiary of a foreign
corporation, foreign firm, or other foreign business.
General Project Information Application Page 13 of 22 Form A-1
Farm ~°y Request for Taxpayer clue rant, to Ute
(Rau Jesaanr zoos, Identification Number and Certification requester. tJo not
°rta°"~'~d'kT1tl°0Y1s
Irtxnd Pes~ua;mice sand to the IRS.
N Name foe $tavn on yxur income tax roam)
+
ra
m _
r+ aurireae namra if digerem tram above
S City of Santa Monica
m~
~p
O ~ Clu:k epprc~pdate bax:~Wl6 proprietor ^Gr orlon
rPar ^ Partnrehip ~ Gdlef ~ .... .............. rxempt from backup
~ Widlheldigg
~ nc~ mbar, sttaat arch apt. or soda na)
1~~ Main Street q ~L'r`a name and addreae a tens
`?' { p' t
L p
Cih, state, fin? ZIP coda
Santa Monica
CA 90401
,
$ Uat exourt nurFUr(ay hero {aptionag
m
Enter }roar TIN in the appropdata box. The TIN pmvidad must match the earns gluon crr Una t to avail Socul seaudty number
backup whhhelding. For individuals, this is your aoeisl accurhy number tSSM. Hawarar, far a rraidart
al~n, sale proprietor, a disregaNsd entity, acre the Pert 1 inatnntiona on page 3. Far other entities, it is
your employer identlfiaation number iEh~q. M yw do not have a number, sea Plow b geE a TIN on page 3. or
Note. N the acaaurt is fn more than me name, see Lha char{ m ,oayta d fx guva:!nee as whose :rumbas Emplayar idemification number
to ~r~-. _ 9 I s1 61 a o o I~ i 9l
Under penalties of perjury, I earthy that:
1. The n umber shave on this farm is my corrert taxpayer idamificaticn number {or I em waiting for a number to ba booed to m61, and
2. I em mt eubj6d to backup withholding because: {a} I am axampt from backup withholding, or fbl I have not 6~en nalifiad by the Internal
Revantw Service (IRS} that I am eubjaet to backup whhhdding as a rasuh of s failure to report all intaree[ ar dividends, or (cj the IRS Ix-ts
naffed me that I am m beget subject m backup withholding, and
3. l am a U.S. pareco iinduding a U.S. resident alianj.
Gerfifice[ion irwtruabre. You moat crcea out ham 2 above if you have bean notified by the IRS that yw era momently aubjea to backup
withholding beeatne yw have failed M span all itrter~at and dividends on your tax return. Far reel eataW 4sneactione. item 2 dace rx~t apply.
For mcrtgege imeraat paid, acquiehian or abandmment a urad property cancallatim a debt, oontributiune to an individual ratiramam
ercangamerrt {IFtty, and gee menm ahertlmn i~ and dividends. yw are not raquircd to sign the Garthcation, but ¢nu moat
provide }roar correct TI iyptructione of rms. S.i j
Here u. pares f ~'` Ci
PUIj31)St? O O'
A person xito is re(auffed to file an iMormation return xfih the
IRS, must obtain your correct tvtpayer identification number
(TIN) to report, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or
contdbufions you made to an IRA
U.S. person. Use Form W-9 only if you are a U.S. pemon
tincluding a resident alianj, to provide your corcact 71N to the
person requesting it {the requasteYl and, when applicable; to:
1. Certify that the TIN you are giving is correct rot you era
waiting for a number to Ge issued},.
2. Certify that you are not subject to lockup wtthhalding,
or
3. Glairn exemption from backup withholding if you era a
U.S. exempt payee. -
Note. li a requester grres you a form afloat than Form W-9 to
request your 7PN, y«r must use the rs.7uaster's form if it is
substar:tlatty sfmSar to ttru Form W-9.
For federal tax purposes ~rou are aansidarad a person if you
are:
• An individual who is a citizen or resident of the United
Stites.
+ A partnership, corporation, company, or association
created or organized in the United States or under the lays
of the United Stags, ar
Cat Mo. tCQ3tX
Manager pate - ~Ld-Y?.r~„s-
+ Any estate {other than a foreign astatej or trust. Sae
Regulations sections 307.7761 -6fa) and 7{a) for additional
information.
'Foreign person. If you are a foreign person, do not use
Form VJ-9. Instead, use the appropriate Force Vd-8 ;er_a
Publication 515, Withholding of Tax on Nonresident Aliens
and Foreign Entitiest.
Nonresident alien who becomes a resident alien.
Generally, only a nonresident alien individual may use the
terms of a tax treaty to raduca or elindnata U.S. tax an
certain types of income. Hovrever, most tax treatise; contain a
provision knrnvn as a "saving clause." Exceptions specified
in the saving clause may permit an exemption from tare to
continue for certain types of income siren after the recipient
has atharwise LiecXrme a U.S. resident alien for tax purpose.
If you are a U.S. resident alien who is relying on an
exception contained in the saving clause of a tax treaty to
claim an exemption from U.S. tax on certain types of income,
}rou must attach a statement to Form VJ-9 that spacifiss the
following five items:
7. The treaty wuntry. Generally, this must be the same
treaty under cahich you claimed aatemption from tax as a
nonresident alien.
2. The treaty article addressing the income.
3. The article numtaer for location} in the tax treaty that
contains the saving clause and hs excepfions.
Farm W-9 tray. t-3rco~
General Project Information Application .Page 14 of 22 Form A-1
Fwm W-e ~Flaa.
4. The type and amount of income that qual~as far the
exemption from tax.
5.3ufficient facts to justify the exemption frtm tax under
the farms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty
allows an exemption from tax for scholarship income
received by a Chinese student temporarily present in the
United States. Under U.S. lau; this student will became a
resident alien for tax purposes if his or her stay in the United
States exceeds 5 calendar years. i'IOweve( paragraph 2 of
the first Protocol to fhe U.S.-China treaty (dated April 30,
~ 9847 allays the provisions of Article 26 to continua to apply
even after the Chinese student becomes a resident ali~ of
the United States. A Chinese student who qual~es for this
exception (under paragraph 2 of the first protocol) and is
relying on this exception to claim an exemption from tax an
his or her scholarship ar felbw~ip income vrould attach to
Form W-9 a statement that includes the information
described above to support that exemption.
M you are a nonresident alien or a foreign entity not subject
to backup withholding, give the requester the appropriate
completed Form W-8.
What is backup withholding? Persons making certain
payments to you must under o3rtain conditions vrithhald and
pay to the IRS 28~Ye of such payments (after December 31,
2002}. This is called "backup vrthholding "Payments that
may to subject to backup withholding include interest,
dividends, broke and barter exchange transactions. rants.
royalties, nonemplayee pay, and certain payments from
fishing boat apemtors. Real eshta transactions are not
subject ip backup withholding.
You will not be subject to backup withholding on payments
you reodva if you give the r~ueater your correct TIN, make
the proper art cations, and report all your taxable interest
and dividends on your tax return.
Payments you receive will be subject to backup
withholding if:
f. Yau do not famish your TIN to the requester, or
2. You do not certify your TIN when required (sae the Part
11 instructions on page 4 for detalls7,or
3. The IR5 falls the requester that you furnished an
incorrect TlN, or
4. The IRS tells you that you era subject to backup
vrithholding because you did not report all your interest and
dividends on your tax return {for reportable interest and
dividends onlyi, or
5. You do Hat certify to the requester that you era not
subject to backup withholding under 4 above ~7or. reportable
interest and dividend accounts opened after 1693 only1.
Certain payees and ~yments era exempt from backup
withholding. See the instructions ttilou° and the separate
Instructions for the Requester of Form V1'-9.
Penalties
Failure to funnish TIN. If you fail to furnish your correct TIN
to a requester, you are subject to a penalty of $50 far each
such failure unless your failure is due to reasonable cause
and not to willful neglect.
Civil penalty for false irNarnation with respect to
withboidirfg. If you make a false statement xfth na
reasonable basis tha4 results in no backup u7thhalding, you
are subject to a $500 penalty.
Criminal penalty for falsifying information. LOfllfully
falsifying certifications or affirmations may subject you to
criminal penalties including fines ancllor imprisonment
Misuse of TINS. If the requester discloses or u°9s TINS in
violation of federal lour, the requester may be subject th civil
and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the Hama
shown on your social security card. Howeaer, if you have
changed your last name, for instance, due to marriage
without informing the Social Security Administration of the
Hama change, enter your first name, the last name shown an
your social security card, and your new last name.
If the aaaaunt is in joint names, list first, and thm circle,
the name of the parson or entity wfiase number you entered
i n Part I of the farm
Sole proprietor. Enter }roar individual Hama as shown on
your social security card an the "Name" line. You may enter
your business, trade, or "doing baslnEF.S as (DBAy' name on
the "Business name° line
Lhnited liability company {LLCy. If }rou era asingle-memlx~
LLG Sincludng a foreign LLG utth a domestic owneq that is
disregarded as an entity separate from its ovmer under
Treasury regulations section 301.7761-3, enter the ovrner's
name on the `Name" line. Enter the LLC's name on the
"Business Hama" Gne. Check the appropriate box foe }cur
filing status (~fe proprietor, carparetion, etc.}, than check
the box for "Other" and enter "LLC" in the space provided.
Other entities. Enter your business name as shown an
required Fademl tax documents an the "Name" line. This
Hama should match the name shown on the charter or other
legal document creating the entity. Yau may eMar any
business, trade, or DBA name on the "Business name" Tina.
Note. You era requested to check the appropriate box for
your status {individualtsole proprietor, corporation, eta).
Exempt From Backup Withholding
If you are exempt, enter your name as dr_scribad stave and
check the appropriate box for your status, than check the
"Exempt from backup vrithholding" box in the line fallovring
the business name, sign and data the form.
Generally, individuals ¢ncluding solo proprietors} are not
exempt from backup vrithholding. Corporations are exempt
fmm backup withholding for certain pa}nnents, such as
interest and dividends.
Note. If you are exempt from backup withholding, you
should still complete this form to avoid possible erroneous
baclap withholding.
Exempt payees, Backup wfthholding is not required on any
payments made to the following payees:
7. An organization exempt from tax under section 56f ta),
any IRA, or a cwtodial acoauM under section 403{bt{7? if the
account satisfies the requirements of section 407 (f}r21,
2. The United States or any of its agencies or
instnunentalities.
3. A state, the District of Columbia, a possession of the
United States, or any of their political subdivisions or
instrumentafitias,
4. Aforeign government or any of its political subdivisions,
agencies, ar instrumentalities, or
5. An intematianal argani~ation or airy of its agencies or
instrumentalities.
Other payees that may be axampt from backup
vrithholding include:
6. A oarporation.
General Project Information Application Page 15 of 22 Form A-1
Firm Y!A ~f7av. t-a}la)
7. A foreign central bank of issue,
$. A dealer in sacudties or commodfti es required to register
in the United States, the Dlstrid of Columbia, or a
possession of the United States,
9. A futures commission merchant registered vrith the
Commodity Futures Tradng Commission;
16. A real state investment trust,
11. An entity ragis~red at all times during the f<ix year
under the Investment Company Act of ~ 940,
22. A common trust fund operated by a bank under
sectiona84(a)..
73. A financial institution,
74. A middleman knamT in the investment community as a
nominee or custodian, or
25. A trust exempt from tax under section 664 or
described in section 4947.
The chart tx4ow shays types of payments that may be
exempt from backup withholding. The chart applies to the
exempt recipients listed above, 1 through t5.
IF tree payment is for ... THEN the payment ie exempt
far...
Interact and diridcnd payments All axampt.radpiente except
for 9
Broker lranaaCtiona Exempt racipienta 2 through 73.
Alm, a paumn registered under
the Ircveatmant Adviaera AG of
t 940 who regulary eMa as e
broker
aartar excl-enge transaaicria Exempt rc<ipiama f through o
end patrorege dividends
Paymetrte over $600 required Genaially, exempt recipients
to he repotted and direct 7 through 7'
salsa aver $3,000 ' _ _
'Sea Form toaaMlSC. Mecailencwe Inavn-, and itn ina[rvcnore.
}Hanaaar. the (alkrrrirg payments rrede to a wgxragon linctudng gr~
prmeada paid to en attorruy urt~ aectipn Bo~S[T], Bran 'rftt» auomey h a
bprl~ar~a~hddin~maipal ~1 a20galSC are not arampt from
P 4 psym_nb. aitarnaya' fees: and
paymarxe fm atrvia3e paid by a rtdarel axe.udva agenyy.
Rart 1. Taxpayer Identification
Number (TIN}
Enter your TIN in the appropriate box. If yynu are a resident
alien and you do not have and are not eliggiL~le to set an SSN,
your TIN is your IRS individual taxpayer identification numLtr
(ITIM. Enter It in the social security nom bar box If you do
not Have an ITIN, sae How to get a TINbelrnu.
If you are a sole proprietor and you have an EIN, you may
enter either your SSN or EIN. However, the IRS prefers that
you use your SSN.
If you era a Jngls-avrner LLG that is disregarded as an
entity separate from its ovmer (sae L'mlfed ?iabNity company
(ttC)an page 2j, enter your SSN (or EIN, ifyau have ones. If
the LLC is a corporation, partnership, eta, enter the amity's
EIN.
Nora. See the chart on page 4 for further clarification of
name and TIN oambinatians.
How to get a TtN. If you da not have a TIN, apply far one
immediately. To apply for an SSN, get Form S3-5,
Application for a Social Security Card, ftnm your local Social
Security Administration office or get this form online at
wsuw.saciadsearritygbv/onlinelss-S.p7f. You may also get this
farm by calling t-$00-772-2273. Use Form W-7; Application
for IRS Individual TaxFxlyer Identification Numtxe~, to aFply
for an ITIN, or Farm SS-4, ApplicaUan far Employer
Identification Number, to apply far an EIN. You can apply for
an EIN online by acet,using the IRS vreC>,ite at
wwwirs.govbusinessesr and clicking ah Employer ID
Numbers under Related Topics. You can get Fomns VJ-7 and
SS-4 from the IRS by visiting wwwirs.gov ar by calling
1-800-TAX-FORM (7 -$CD-829-3676Y.
If you are asked to complete Forrn 4~'-9 but do not haoe a
TIN, write Applied For" in the space for the TIN, sign and
date the form, antl give if to the requester. Far interest and
dividend payments, and certain payments made moth rasped
to readily tradable instruments, generally you vrill have 60
days to get a T1N and give it to the requester before you era
subject to backup withholding on paymems. The 60-day rule
does not apply to other types of payments. You will be
subject to backup withholding on all such payments until you
provide your TIN m the requester.
Note, Writing "Applied For" m47ns that you have already
applied far a TIN or that you intend to apply for one soon.
Caution: A disregarded dwr:autic entity dfat has a foreign
oxmer must use the apprt~priate Form Vi'-3.
General Project Information Application Page 16 of 22 Form A-1
Fum wA (Rev. t-~s5f
Part IL Gertificatian
Ta estabilsh to the withholding agent that you are a U.S.
parson, or resident alien, sign Farm',N-9. Yau may ba
requested to sign by the withholding agent even if items 1, A.
and 5 below indicate otharvrise.
For a joint account onty the parson whose TIN is shown in
Part I should sign flan required). F~tempt recipients, see
Exen7pf Fran Backup WiMhard~ag on page 2.
Signature requirements. Complete the certification as
indicated in 1 through 5 belov.•.
1. Interest, dividen$ and barter exchange accounts
opened before 198A and broker accounts considered
active during.1983. You must give your corral TIN, but you
do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange
accounts opened after t983 and brakar accounts
considered thactive during 1988. Yau must sign the
certification or backup v~ithholding will apply. If you era
subject to backup withholding and you are merely providing
your correct TW to the requester, you must crass out item 2
in the aertific~ttbn before signing the form.
8. Real estate transactions. You must sign the
certification. You may cross. aut item 2 of the oartification.
4.Other payments. You must give your correct TIN, but
you do not have to sign the cert'rfication unless you have
bean notified that you have previously given an incorrect TIN.
"Other payments" include payments made in the course of
the requester's trade or business far rents. royalties, goods
fothar than bills for merchandise), medical and health care
servloas {including payments to corpamfions}, payments to a
nonemployee for services, payments to certain fishing boat
crew members and fisherman, and grams proceeds paid to
attorneys {including payments to ~rporations).
5. Mortgage interest paid by you, acquisition or
abandonment of secured property, cancellation of debt;
qual~ed tuftion program payments {under section 529j,
IRA, Coverdell ESA, Archer MSA ar HSA contributions or
distributions, and pension distribu6ans.You-must glue
your correct TIN, but you do not have to sign the
certification.
What Name and Number To Give the
Requester
For tbla a of account: Give name and SSN oF.
1. Individual The individual
2. Taro or more indniduals (joint The acttal oenar of the axwrrt
accoumj on ff wmbinad tondo, the first
individual on the account'
3. Custodian atCwnt of a minor The minor'
tUnitonn Gift i7 Minaw Aoti
3. a. Tha uauai revocable The grarrtor-tmata3 '
savings foist (gmnWr is
also trtwtaej
6. So-called float eCNUnt Tha actual ovnar'
that is not a bgal or valid
trust under emote law
~. SoH proprietorship u Tha aa~nar'
aingHowner LLC
For this type of account: Give Hama and FJN of:
6. Sofa prepdetorahip or The avner'
airglaownar LLC
7. A valid trust, estate, or Legal entity '
peraion trust
8. Corpwata or LLC ekwting The ccrporetien
corpo~e smtua on Fa~m
6632
9. Aesadetion, club, rAigious, The crgan¢aticn
dtedtable, educatWnal, or
other tax-cr~mpt agan¢eticn
10. Partn6rahip or multi-member Tha partnership
LLC
tt. A broker cr ragiaterad Tha brekar cr nominee
nominee
12. Accwnt tv@h the Department The public erNty
of Agriwhura in the names of
a public enthy lsuchsa a
elate cr Ixel gavammarrt,
aloof district, or preanj that
receives agdcukurel program
paymam8
'List first and stab the nano of the paten ~xhcas number yw fumroh. H
rnly ore perean on a join ~oYlnt h~ an SSN, ttet parecn'a nunba must
bs fumelad.
'Cimla the mirxx's name ant furridr the mirxr'e SSN
'You moat dtax yxur ndioidusl natty ant pea may alai smar ywr bueireae
a "OBA' Hems on the aaoond nvna lira. You may ass eaha year SSW ~s
EIN (d you hn~a ansj. H you are a sob poprtor, IRS eroaw}e yxu to
uaa your SSN
' fiat fir># and etch the rams of the 4a)al tncet. aateta, ar p neon toot. (Do
net turriahtAa TIN of the pascaal reprassmati~.a or trust a rnlc~a the lags{
entity aedf re net designated in the acaum title.}
Note. If no name is circled wflen more than one name is
listed, the number will be considered to ba that of the first
Herne listed.
Privacy Act Notice
Section 6{49 of the IntamaF Revenue Code requires you to provide your correct TIN to parsons who must file information returns
vrith the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisdion or
abandonment of scoured property, rancellafion of debt, or cantributims you made to an IRA, or Archer fviSA or HSA The IRS
uses the numbers for identification purposes and to help verify the axumay of your tax return. The IRS may also provide this
information to the Department of Justice for civil and criminal litigation, and to cities. states, and the District of Columbia to carry
out their tax lave. YJe may also disclose this information to other countries and?r a tax treaty, to fxJeral and shte agancias to
enforce federal nontax criminal laws, or to federal lav.• enforcement and intelligence agancias to combat tarrodsm.
You must provide your TIN whether or not you era required to file a tax return. Payers must genaralty k~ithhold 2$ga, of taxable
interest, dividend, and certain other payments to a payee who does not glue a TIN to a payee Certain penalties may also apply.
General Project Information Application Page 17 of 22 Form A-1