MONTEREY BAY UNIFIED AIR POLLUTION CONTROL DISTRICT

CARL MOYER PROGRAM ANNUAL USE REPORTING REQUIREMENTS As stated in the Grant Acceptance Agreement (GAA), Carl Moyer grant recipients must submit an annual use report for the term listed in the GAA. The report shall provide data on operation, such as annual gallons, annual miles traveled, annual hours operated, maintenance, and any other pertinent information requested by the Monterey Bay Unified Air Pollution Control District (MBUAPCD) for the engine/vessel/vehicle/equipment/electric motor. The annual report is used to verify that the engine/vessel/vehicle/equipment/electric motor is in good working order and within the required annual gallons/miles/hours of operation. Carl Moyer Program Annual Use Report Forms are available on the MBUAPCD website at www.mbuapcd.org under Grants and Incentives, Carl Moyer Program. All Grantees are required to submit an Annual Use Report Form once per calendar year as required by the GAA. Any noncompliance with annual reporting requirements will result in an onsite inspection. Noncompliance means failing to submit a complete annual use report. In instances where annual usage is significantly lower than the amount listed in the GAA, due to unforeseen circumstances, the Grantee may request a waiver from MBUAPCD. Please contact Nathan Pierce at 831-647-9418, ext. 243 if you have questions.

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Carl Moyer Program Annual Use Report Form Instructions: This section outlines the information requirements for each field of the Annual Use Report Form. Please fill out a separate Annual Use Report form for each engine/vehicle/equipment/electric motor listed in the GAA. If you need additional assistance, please contact Nathan Pierce at 831-647-9418, ext. 243. 1.

GRANTEE INFORMATION

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Grant Agreement Number: The agreement number is the number MBUAPCD assigned to your GAA. The agreement number can be found at the top right corner of the first page of your GAA.

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Contact Name: The first and last name of the person serving as the primary contact to MBUAPCD through the life of project.

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Business/Organization Name: The business/organization legal name listed in the GAA.

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Mailing Address, City, State and Zip: The business/organization physical address, city, state, and zip.

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Business/Organization Phone Number: The business/organization main phone number, including area code.

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Contact Phone/Cell Number: The business/organization primary contact phone and cell number.

2.

EQUIPMENT INFORMATION

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Make/Year/Model: Make, Year and Model of equipment.

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Marine Vessel Name (if applicable): Name of Marine Vessel.

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Marine Vessel Registration Number (if applicable): Registration Number for Marine Vessel.

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Location of Equipment: Primary location of the engine/vessel/vehicle/equipment/electric motor listed in the GAA.

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Meter Readings: Readings of the usage meter such as hour meter or odometer.

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Significant Changes in Usage: If applicable, identify any conditions (such as weather, permits, regulations, major maintenance, etc.) that impacted annual usage. If annual usage is significantly lower than the amount identified in the GAA, MBUAPCD may grant the project a waiver. Please contact Nathan Pierce, Planner II at (831) 647-9418 ext. 243 with questions regarding low usage.

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Comments: Provide any further comments concerning this equipment.

3.

ENGINE USAGE INFORMATION

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Engine Serial Number: Provide the Engine Serial Number of engine.

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Annual Usage: Provide the annual usage in gallons, hours or miles.

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Percent operated in California: Enter the percentage of time operated within California.

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Percent operated in MBUAPCD: Enter the percentage of time operated within MBUAPCD (Monterey, Santa Cruz and/or San Benito Counties).

4. AGREEMENT AND SIGNATURE: •

Agreement: Read agreement section prior to signing the Carl Moyer Program Annual Use Report.

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Date: The date the Carl Moyer Program Annual Use Report is signed.

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Print Name: Printed name of person who has the authority to submit and sign the Carl Moyer Program Annual Use Report.

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Signature: Signature of person who has the authority to submit the Carl Moyer Program Annual Use Report.

Please return the completed Carl Moyer Program Annual Use Report Form by March 2, 2012 to: Monterey Bay Unified Air Pollution Control District 24580 Silver Cloud Court Monterey, California 93940

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Carl Moyer Program Annual Use Report Calendar Year 2011 (Note: Fill out one form for each grant number.)

1. Grantee Information Grant Agreement Number: Contact Name: Business/Organization Name: Business/Organization Address: City:

State:

Business/Organization Phone Number: ( Primary Contact Phone Number: (

Zip: )

)

Cell: (

Year:

Model:

2. Equipment Information Make:

Marine Vessel Name (if applicable): Marine Vessel Registration Number (if applicable): Location of Equipment: Meter Readings: Significant Changes in Usage: (See Form Instructions)

Comments: (Provide any further comments concerning this equipment.)

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)

3. Engine Usage Information

Report 2011 Usage (Gallons, Hours or Miles) 1/1/2011 through 12/31/2011 Annual Usage Engine Serial Number: (gallons, hours or miles)

Percent Operated in California

Percent Operated in MBUAPCD (Monterey, Santa Cruz, and/or San Benito counties)

% 4. Agreement and Signature Agreement: I certify this information to be correct and accurate. I will retain records documenting the amounts entered herein for five years.

Date:

Print Name:

Signature:

Return and Mail to: Monterey Bay Unified Air Pollution Control District 24580 Silver Cloud Court Monterey, Ca. 93940 For questions please contact Nathan Pierce, Planner II at (831) 647-9418 ext. 243 or at [email protected]

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