Exhibit D1 Diesel Truck Idling Reduction Grant
|State of Wisconsin |[pic] |RETURN COMPLETED FORM TO: |
|DEPARTMENT OF ADMINISTRATION | |WI DEPARTMENT OF ADMINISTRATION |
|DIVISION OF ENERGY, HOUSING & COMMUNITY RESOURCES | |ATTN: WI DIESEL TRUCK IDLING REDUCTION GRANT PROGRAM |
|DOA-9564 (R05/2016) | |101 E. WILSON ST., P.O. BOX 7970 |
| | |MADISON, WI 53707-7970 |
|EXHIBIT C3 DIESEL TRUCK IDLING REDUCTION GRANT PROGRAM 12-MONTH REPORT |
|12-MONTH REPORT - FLEET & TRUCK INFORMATION (A COPY OF AN ENGINE DOWNLOAD MUST BE INCLUDED WITH THE SUBMITTAL OF THIS REPORT.) |
| |CONTRACT NUMBER: | |GRANT RECIPIENTS ARE REQUIRED TO ANSWER EVERY QUESTION. |
| |BUSINESS NAME OR OWNER OPERATOR NAME: | |DATE OF ENGINE DOWNLOAD: | |
| |12 MONTH REPORT START DATE: | |END DATE: | |
|LONG HAUL TRUCK TRACTOR(S): |TRUCK 1 |TRUCK 2 |TRUCK 3 |TRUCK 4 |
|1 |VEHICLE IDENTIFICATION NUMBER: | | | | |
|2 |UNIT NUMBER (IF APPLICABLE): | | N/A | | N/A |
|4 |TRUCK MODEL: | | | | |
|6 |ENGINE MAKE: | | | | |
|7 |ENGINE MODEL: | | | | |
|8 |ENGINE MODEL YEAR: | | | | |
|9 |
|12 |TOTAL MILES TRAVELED (PAST YEAR): | | | | |
|13 |TOTAL MILES TRAVELED IN WISCONSIN (PAST YEAR): | | | | |
|14 |ESTIMATE THE TOTAL MILES TRAVELED IN WISCONSIN NON-ATTAINMENT1 COUNTIES: | | | | |
|15 |AVERAGE MILES PER GALLON: | | | | |
|16 |AVERAGE IDLING TIME (HOURS/MONTH): | | | | |
|17 |AVERAGE IDLE PERCENTAGE TIME (%): | % | % | % | % |
|18 |ESTIMATE THE AVERAGE IDLING TIME IN WISCONSIN NON-ATTAINMENT1 COUNTIES (HOURS/MONTH): | | | | |
|19 |TYPE OF FUEL USED (ULSD, B-100, B-20, B-5, CNG, LNG, LPG, E-85): |ULSD | |ULSD | |
|APPROXIMATELY WHAT PERCENTAGE (%) HAS THE TRUCK TRAVELED IN THE FOLLOWING AREAS: (PLEASE USE WHOLE NUMBERS ONLY.) |
|21A |MIDWEST2 | % | % | % | % |
|21B |NORTHEAST2 | % | % | % | % |
|21C |SOUTH2 | % | % | % | % |
|21D |WEST2 | % | % | % | % |
|THE IDLE REDUCTION TECHNOLOGY INSTALLED: |TRUCK 1 |TRUCK 2 |TRUCK 3 |TRUCK 4 |
|22 |TYPE: AUXILIARY POWER UNIT (APU), BATTERY AIR CONDITIONING SYSTEM (BP), DIRECT FIRED HEATER (DFH), THERMAL STORAGE | | | | |
| |SYSTEM (TSS), OTHER (PLEASE SPECIFY): | | | | |
|23 |MANUFACTURER OF THE IDLING REDUCTION UNIT: | | | | |
|24 |IDLE REDUCTION UNIT MODEL: | | | | |
|25 |IDLE REDUCTION UNIT MODEL YEAR: | | | | |
|DOA-9564 CONTINUED |
|IN YOUR OPINION (PARTS OF THIS SECTION SHOULD BE COMPLETED BY THE TRUCK DRIVER, AS APPLICABLE): |TRUCK 1 |TRUCK 2 |TRUCK 3 |TRUCK 4 |
|23 |HOW WOULD YOU RATE THE IDLING REDUCTION UNIT? |
|23A |NOISE (VERY LOUD, QUITE LOUD, SOMEWHAT LOUD, NOT LOUD) | | | | |
|23B |CAB COMFORT (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | | | | |
|23C |EASE OF USE (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | | | | |
|23D |EFFICIENCY (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | | | | |
|23E |OVERALL (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | | | | |
|24 |WOULD YOU ENCOURAGE A FELLOW DRIVER TO PURCHASE THE SAME IDLE REDUCTION UNIT AS YOURS? | YES NO | YES NO | YES NO | YES NO |
|25 |WOULD YOU HAVE PURCHASED THE IDLING REDUCTION TECHNOLOGY WITHOUT ASSISTANCE FROM THE DIESEL TRUCK IDLING REDUCTION | YES NO | YES NO | YES NO | YES NO |
| |GRANT PROGRAM? | | | | |
|26 |WHAT BENEFITS HAVE YOU REALIZED THROUGH THE INSTALLATION OF THE IDLING REDUCTION EQUIPMENT; THE PRO'S AND CON'S (EX:,| |
| |COMFORT, FINANCIAL SAVINGS, ETC): | |
|27 |IF THE DIESEL TRUCK IDLING REDUCTION GRANT PROGRAM WAS NO LONGER BEING OFFERED, WHAT DO YOU THINK IS THE BEST WAY TO ASSIST FLEETS IN PURCHASING IDLE REDUCTION TECHNOLOGIES? |
|27A |TAX INCENTIVES (CHOOSE ONE): (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | |
|27B |LOW-INTEREST LOAN PROGRAMS FROM THE GOVERNMENT (CHOOSE ONE): (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | |
|27C |LOW-INTEREST LOAN PROGRAMS FROM FINANCIAL INSTITUTIONS (CHOOSE ONE): (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | |
|27D |TAX REBATES (CHOOSE ONE): (NOT USEFUL, SOMEWHAT USEFUL, QUITE USEFUL, VERY USEFUL) | |
|27E |OTHER: (PLEASE SPECIFY) | |
|28 |WHAT FACTORS MOTIVATED YOU TO PARTICIPATE IN THIS GRANT PROGRAM? | FUEL SAVINGS | ENVIRONMENTAL BENEFITS | FINANCIAL INCENTIVES | CAB COMFORT |
|29 |WHAT IMPROVEMENTS WOULD YOU LIKE TO SEE MADE TO THE DIESEL TRUCK IDLING REDUCTION GRANT PROGRAM? (PLEASE EXPLAIN): |
| | |
| |1WISCONSIN OZONE NON-ATTAINMENT COUNTIES INCLUDE: KENOSHA, RACINE, MILWAUKEE, WAUKESHA, WASHINGTON, SHEBOYGAN, OZAUKEE, MANITOWOC, KEWAUNEE, AND DOOR. |
| |2MIDWEST: INDIANA, ILLINOIS, IOWA, KANSAS, MICHIGAN, NEBRASKA, MINNESOTA, MISSOURI, NORTH DAKOTA, OHIO, SOUTH DAKOTA, WISCONSIN |
| |2NORTHEAST: CONNECTICUT, MAINE, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY, NEW YORK, PENNSYLVANIA, RHODE ISLAND, VERMONT |
| |2SOUTH: ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, LOUISIANA, MARYLAND, MISSISSIPPI, N. CAROLINA, OKLAHOMA, S. CAROLINA, TENNESSEE, TEXAS, VIRGINIA, W.VIRGINIA |
| |2WEST: ARIZONA, CALIFORNIA, COLORADO, IDAHO, MONTANA, NEW MEXICO, NEVADA, OREGON, UTAH, WASHINGTON, WYOMING |
| |I CERTIFY THAT THE INFORMATION WITHIN THIS REPORT IS CORRECT AND WAS DERIVED FROM ON-BOARD, ELECTRONICALLY RECORDED DATA. |
| | | |QUESTIONS FILLING OUT THIS REPORT? |
| | | |Contact Jean Beckwith at |
| | | |Jean.Beckwith@ |
| | | |or 608/261-2517 |
| | | | |
| |Signature | |Date | |
| | | | | |
| | | | |
| |Facility Contact | |Title | |
| |
| |Geographical map is from the U.S. Census: |
| |Retain a copy of the completed form for your records and fax (608/267-6931), email (Jean.Beckwith@) or mail to: |
| |Wisconsin Department of Administration, Diesel Truck Idling Reduction Grant Program, DECHR 6th Floor PO Box 7970, Madison, WI 53707-7970 |
| |or for additional copies go to: |
This form can be made available in alternate formats to individuals with disabilities upon request.
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