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October 2008 CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY Integrated Waste Management Board (CIWMB) TIRE-DERIVED PRODUCT (TDP) GRANT PROGRAM APPLICATION 7th Cycle (TDP7) – Fiscal Year (FY) 2008/09 Table of Contents  Grant Application........................................................................................................................................ 1 Environmental Justice Certification............................................................................................................ 3 Funding Acknowledgement ........................................................................................................................ 3 Acceptance of Grant Provisions.................................................................................................................. 3 Project Description...................................................................................................................................... 3 Proposed Work Plan ................................................................................................................................... 4 Resolution or (Letter of Commitment) Requirement.................................................................................. 5 Environmentally Preferable Purchases And Practices Policy Requirement ............................................... 5 Private School Eligibility Certification Requirements ............................................................................... 5 Application Certification ............................................................................................................................ 5 Application Checklist.................................................................................................................................. 9 Mailed Applications must be postmarked no later than November 21, 2008. Hand delivered Applications must be received and date stamped by CIWMB Staff no later than 3:00 p.m. on November 21, 2008. Late Applications will be disqualified. Applications e-mailed or faxed will not be accepted. Please follow instructions in the Application Guidelines and Instructions when completing this Application. The Application Guidelines and Instructions are critical to properly completing and submitting this Application. Applications become the property of the CIWMB and are subject to disclosure under the Public Records Act. Do not submit confidential information. Applications sent by U.S. Postal Service or a commercial delivery service should be sent in a manner that allows for tracking by the sender and that provides an addressed and dated receipt. Failure to do so is at the risk of the applicant and if delivery is delayed or the application is lost by the Post Office or delivery service, the burden is on the applicant to demonstrate timely mailing or delivery of the application. Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 1 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GRANT APPLICATION FORM CIWMB 243-TDP (New 10/08) Tire-Derived Product (TDP) GRANT PROGRAM – TDP7 (FY 2008/09) Complete and submit all sections. APPLICANT / ORGANIZATION INFORMATION APPLICANT / ORGANIZATION NAME (MUST MATCH RESOLUTION OR LETTER OF COMMITMENT): REQUESTED GRANT AMOUNT: (ROUND AMOUNTS TO $ THE NEAREST WHOLE DOLLAR) MAILING ADDRESS: PROJECT ADDRESS: (LIST ALL LOCATIONS) CITY: CITY: COUNTY: ZIP CODE: COUNTY: ZIP CODE: SIGNATURE AUTHORITY NAME: AUTHORIZED DESIGNEE NAME: (AS AUTHORIZED IN RESOLUTION OR LETTER OF COMMITMENT) (IF APPLICABLE, AS AUTHORIZED IN LETTER OF AUTHORIZATION-LOA) TITLE: TITLE: TITLE: TELEPHONE NUMBER: TELEPHONE NUMBER: TELEPHONE NUMBER: FAX NUMBER: FAX NUMBER: FAX NUMBER: EMAIL ADDRESS: EMAIL ADDRESS: EMAIL ADDRESS: PRIMARY CONTACT NAME: INDICATE WHICH TYPE OF ENTITY YOU ARE (CHECK ONLY ONE): CITY & COUNTY PUBLIC SCHOOL DISTRICT SPECIAL DISTRICT PARK DISTRICT QUALIFYING CALIFORNIA INDIAN TRIBE FIRE DEPARTMENT POLICE/SHERIFF DEPARTMENT CITY COUNTY COLLEGE OR UNIVERSITY PRIVATE SCHOOL – non-profit, private K-12 school listed on the most recent California Department of Education Private School Affidavit List and defined as low income per qualification for the National School Lunch Program. COMMUNITY HOUSING DEVELOPMENT ORGANIZATION (CHDO) – non-profit, low-income housing entities, currently certified as CHDOs by the California Department of Housing and Community Development (HCD) ARE YOU A “LARGE PUBLIC SCHOOL DISTRICT” DEFINED AS HAVING AT LEAST 43,000 STUDENTS? YES NO LEGISLATIVE DISTRICT NUMBERS (TO FIND YOUR DISTRICT, USE MAILING ADDRESS ABOVE AND GO TO www.ciwmb.ca.gov/Profiles/Juris/) ASSEMBLY: SENATE: FEDERAL TAX IDENTIFICATION NUMBER: INDICATE WHICH TYPE OF TIRE DERIVED PRODUCT YOU ARE APPLYING FOR: PRODUCT / PROJECT INFORMATION – FOR PUBLIC ENTITIES & CHDOS ONLY (PRIVATE SCHOOLS NEXT PAGE) AGRICULTURE/LANDSCAPE: RECREATION: TRANSPORTATION: MULCH OR BARK PLAYGROUND GUARD RAILS OR COMPONENTS WEED ABATEMENT COVERINGS TRACK RAILROAD TIES TREE CARE PRODUCTS SIDEWALK/PATHWAY SOUND BARRIERS HORSE STALL MATS/ARENAS SPORTS SURFACING TRAFFIC SAFETY PRODUCTS OTHER: OTHER: OTHER: Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 2 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GRANT APPLICATION FORM CIWMB 243-TDP (New 10/08) PRODUCT / PROJECT INFORMATION – FOR PRIVATE SCHOOLS ONLY AGRICULTURE/LANDSCAPE: TRANSPORTATION: MULCH OR BARK GUARD RAILS OR COMPONENTS WEED ABATEMENT COVERINGS RAILROAD TIES TREE CARE PRODUCTS SOUND BARRIERS OTHER: TRAFFIC SAFETY PRODUCTS OTHER: ENVIRONMENTAL JUSTICE CERTIFICATION CIWMB Grantees must in the performance of the Grant Agreement conduct their programs, policies, and activities that substantially affect human health or the environment in a manner that ensures the fair treatment of people of all races, cultures, and income levels, including minority populations and low-income populations of the State. (Govt. Code §65040.12(e) and Public Resources Code §71110(a)) Must check box We acknowledge that our organization will comply with these principles of Environmental Justice. FUNDING CERTIFICATION See Application Guidelines & Instructions for Grant Program Administration information Must check box We certify that our organization has or will have the additional funds needed to complete the project by the end of the grant term. ACCEPTANCE OF GRANT PROVISIONS Visit the TDP website to download Grant Administration Documents http://www.ciwmb.ca.gov/Tires/Grants/Product/FY200809/default.htm Must check box By checking this box, Applicant acknowledges that submittal of this application constitutes acceptance of all Grant Agreement provisions as contained in the Application Guidelines and Instructions, Terms and Conditions, and Procedures and Requirements. PROJECT DESCRIPTION Provide a brief description of the project(s) below (3-5 sentences). Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 3 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GRANT APPLICATION FORM CIWMB 243-TDP (New 10/08) PROPOSED WORK PLAN List the individual activities, tasks or subtasks, and timelines necessary to complete the project(s). Note: If additional space is needed, the Work Plan may be reproduced as necessary. Pre-Installation Phase Task # Task Description Product or Results Timeframe (use dates) Task Description Product or Results Timeframe (use dates) Task Description Product or Results Timeframe (use dates) Installation Phase Task # Post-Installation Phase Task # Note: See Application Guidelines & Instructions for example. Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 4 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GRANT APPLICATION FORM CIWMB 243-TDP (New 10/08) RESOLUTION or LETTER OF COMMITMENT REQUIREMENT Submit either an approved Resolution or Letter of Commitment, valid up to 5 years, with your application or the following acknowledgement (If applicable, submit a current Letter of Authorization (LOA) for signature designee) See Application Guidelines & Instructions for Resolution, Letter of Commitment and Letter of Authorization (LOA) information and example. Must check one For entities with governing bodies: We acknowledge that an approved Resolution and, if applicable, LOA designating additional signature authority is enclosed in the application. For entities without governing bodies: We acknowledge that a letter bearing entity’s letterhead, signed by person with authority to contractually bind entity, authorizing application and designating signature authority is enclosed in the application. We acknowledge that our approved Resolution must be received by the CIWMB no later than January 12, 2009. We further acknowledge that if our Resolution is received after this date, our application will be disqualified. ENVIRONMENTALLY PREFERABLE PURCHASES AND PRACTICES POLICY REQUIREMENT Acknowledgement that your organization has an Environmentally Preferable Purchases & Practices Policy See Application Guidelines & Instructions for example and notification Must check one Yes, our organization has an Environmentally Preferable Purchases and Practices Policy. Date adopted: No, our organization does not have an Environmentally Preferable Purchases and Practices Policy. We acknowledge that our organization must adopt one, send notification to the CIWMB of such adoption, and must be received by CIWMB no later than January 12, 2009, or our application will be disqualified. -FOR PRIVATE SCHOOLS ONLYPRIVATE SCHOOL ELIGIBILITY CERTIFICATION REQUIREMENTS Must check all Declaration of non-profit status issued by the Internal Revenue Service Most recent Letter of Good Standing issued by the California Franchise Tax Board Copy of the most recent Certificate of Good Standing issued by the Secretary of State Documentation that the school is currently qualified for the National School Lunch Program by the U.S. Department of Agriculture APPLICATION CERTIFICATION Certification: I declare, under penalty of perjury under the laws of the State of California, that I have read all information in the Application Guidelines and Instructions and that all information submitted for the CIWMB’s consideration for award of grant funds is true and accurate to the best of my knowledge. X Signature Authority - as authorized in Resolution or Letter of Commitment; or Authorized Designee - as authorized in submitted Letter of Authorization Date Print Name Print Title Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 5 STATE OF CALIFORNIA California Integrated Waste Management Board CIWMB 227 - for TDP7Cycle (Revised 08/08) Applicant/Grantee Name: Grant # (if applicable): Tire-Derived Product (TDP) Certification The TDP Certification form must accompany the grant application and all payment request forms. By signing this form, the signatory certifies, under penalty of perjury, that the information provided below by the product manufacturer or supplier is true and accurate. Procedure 1. Applicant/Grantee: Request completion of this form by product manufacturer or supplier. 2. Product Manufacturer or Supplier: Complete and submit form, with original signature, to applicant/grantee. Supply applicant/grantee with and retain supporting documentation 100% CA waste tires were used for this grant project 3. Applicant/Grantee: Review form for completeness and submit form, with original signature, to CIWMB with your grant application and all payment request forms. Retain supporting documentation that 100% CA waste tires were used for this grant product/project. MANUFACTURER / PRODUCT SUPPLIER NAME: EMAIL: CONTACT NAME: PHONE: ADDRESS: WEBSITE: Product Description & Type Rubber -- Mulch Product Weight in lbs. (CA Waste Tires) 115,500 lbs. / (divided) / EXAMPLE Passenger Tire Equivalent (PTE) = (Use 12 lbs. or 20 lbs.*) 12 lbs. = 1 tire FAX: Number of Tires Diverted Cost Per Tire X (In PTEs) = (CIWMB will reimburse up to $5 per tire diverted – may include shipping & tax, not to exceed $5) Material Cost = X 9,625 PTEs $ 3.79 = $ 36,478 / X $ = $ / = X $ = $ / Totals: = = X $ = $ / = X $ = $ * Passenger Tire Equivalent (PTEs): If a TDP contains less than 30% (by weight) of the original fiber and steel that was in the whole tire, then use 12 lbs. to calculate the number of PTEs. If a TDP contains 30% or more (by weight) of the original fiber and steel that was in the whole tire, then use 20 lbs. to calculate the number of PTEs. I certify, under penalty of perjury, that the quote and/or material provided to the above named grantee is manufactured from 100% California waste tires and does not include truck tire buffings. I understand that if an audit discloses the use of non-California waste tires or truck tire buffings, the California Integrated Waste Management Board may require the grantee to return funds up to the grant amount, and the grantee may seek reimbursement from the above named manufacturer, product supplier, contractor. Signature of Product Manufacturer / Supplier Tire-Derived Product Grant Program – TDP7 (FY 2008/09) Print Name Title Date 6 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GENERAL CHECKLIST OF BUSINESS PERMITS, LICENSES AND FILINGS CIWMB 669 (Revised 9/07) GRANT APPLICANT/GRANTEE NAME GRANT NUMBER, IF APPLICABLE GRANT NAME AND CYCLE Mark ( DATE SUBMITTED/UPDATED or X) appropriate box on each line below. All lines must be completed. Note: This list is not all-inclusive. Grant Applicant/Grantee must list other critical permits/licenses/filings not identified below. Grant Applicant/Grantee currently holds this valid permit/license/filing Grant Applicant/Grantee will modify and/or obtain this permit/license/filing This permit/license/filing is not applicable for this grant project or business LOCAL PERMITS, LICENSES & FILINGS REGULATOR OR ISSUER Authority to Construct/Permit to Operate Air Quality Management District Building Construction Permit City or County Business License City or County Fictitious Business Name Filing County Land Use Permit/Zoning Clearance/Conditional Use Permit City or County Permit By Rule (PBR) for Permanent HHW Facilities or Temporary Collection Events Waste Hauler Permit City, County or Cal/EPA-DTSC City or County STATE PERMITS, LICENSES & FILINGS Antifreeze, Battery, Oil & Paint (ABOP) Notification CUPA or Cal/EPA-DTSC Corporate, Company or Partnership Filings Ca. Secretary of State Hazardous Waste Haulers Permit Cal/EPA – DTSC Industrial Activities Storm Water General Permit Cal/EPA – SWRCB Non-Profit Organization 501 (C) (3) Ca. Secretary of State Prop. 65 Safe Drinking Water & Toxic Enforcement Act Cal/EPA – OEHHA Solid Waste Facilities Permit Cal/EPA – CIWMB State EPA Identification Number Cal/EPA – DTSC Waste and Used Tire Hauler Registration Cal/EPA – CIWMB Waste Discharge Requirements Cal/EPA – SWRCB Waste Tire Facilities Permit Cal/EPA – CIWMB FEDERAL PERMITS, LICENSES & FILINGS US EPA – Identification Number US EPA US EPA – NPDES and/or NSR Permits US EPA OTHER PERMITS, LICENSES & FILINGS DO NOT submit copies of the permits/licenses/filings with this form. Please retain all permits/licenses/filings in grant file for audit purposes. Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 7 STATE OF CALIFORNIA CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD GENERAL CHECKLIST OF BUSINESS PERMITS, LICENSES AND FILINGS CIWMB 669 (Revised 9/07) Comments/Notes: Mark ( or X) appropriate box below. PRIVATE ENTITY CERTIFICATION: I declare under penalty of perjury under the laws of the State of California that the proposed grantee: 1) is in good standing and qualified to do business in the State; and 2) has or will comply with all applicable state, federal, and local laws, ordinances, regulations, license and permit requirements necessary for the proper performance of this grant; and 3) where compliance has not been met, I have attached a letter describing what has been done to achieve full compliance. PUBLIC ENTITY CERTIFICATION: I declare under penalty of perjury under the laws of the State of California that the proposed grantee: 1) has or will comply with all applicable state, federal, and local laws, ordinances, regulations, license and permit requirements necessary for the proper performance of this grant; and 2) where compliance has not been met, have attached a letter describing what has been done to achieve full compliance. on Executed at: City and State X Signature Authority / Authorized Designee Date Date (as authorized in Resolution or Letter of Authority-LOA) Print Name Print Title Note: Falsification under penalty of perjury may result in criminal and civil penalties. In addition, pursuant to the terms of the grant agreement, any misrepresentations in the above certification shall constitute a breach of contract that could result in non-payment of grant funds to the grantee; relinquishment by the grantee of funds previously paid; termination of the grant; and/or placing the grantee on the Board’s Unreliable Contractors List. Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 8 APPLICATION CHECKLIST This application checklist is provided for your convenience and is not intended to be all inclusive. Prior to submitting your application, check the Q&A website at; http://www.ciwmb.ca.gov/Tires/Grants/Product/FY200809/Apply/QandA.htm, for additional information. You are responsible for completing and submitting all required documentation. Grant Application Form (CIWMB 243-TDP) All applicable information and documents are provided; applicable boxes are checked. Application Certification is signed by the: 1) Signature Authority as authorized in Resolution or Letter of Commitment, or 2) Authorized Designee. Authorized Designee may sign only if the Letter of Authorization has been submitted to the CIWMB. Environmental Justice Certification Box is checked. Funding Acknowledgment Box is checked. Acceptance of Grant Provisions Box is checked. Project Description A brief description of the project is provided. Proposed Work Plan Activities, tasks or subtasks, and timelines necessary to complete the project(s) are listed. Resolution or Letter of Commitment Requirement— See Application Guidelines & Instructions for information and examples Approved Resolution or Letter of Commitment is included with Application; box is checked, or If applicable, approved Resolution not submitted with Application but will be submitted to the CIWMB for receipt by January 12, 2009; box is checked. If applicable, Letter of Authorization (LOA) is included with Application. A LOA is not required to be submitted with the Application; however, it must be submitted prior to Designee’s exercise of his/her authority. Environmentally Preferable Purchases and Practices Policy Requirement— See Application Guidelines & Instructions for example & notification Signature Authority has certified that Applicant has an Environmentally Preferable Purchases and Practices Policy (EPPP Policy); box is checked, or Applicant does not have an EPPP Policy but will adopt one and submit a Notification to the CIWMB for receipt by January 12, 2009; box is checked. FOR PRIVATE SCHOOLS ONLY – Private School Eligibility Certification Requirements Declaration of non-profit status issued by the Internal Revenue Service Most recent Letter of Good Standing issued by the California Franchise Tax Board Copy of the most recent Certificate of Good Standing issued by the Secretary of State Documentation that the school is currently qualified for the National School Lunch Program by the U.S. Department of Agriculture Tire-Derived Product (TDP) Certification Form (CIWMB 227-for TDP7 Cycle) A completed Tire-Derived Product (TDP) Certification form (CIWMB 227-for TDP7 Cycle) is submitted with your application. General Checklist of Permits, Licenses, and Filings (CIWMB 669) A completed General Checklist of Permits, Licenses, and Filings (CIWMB 669) is submitted with your application. Application Format & Submittal Copies: One application with original signature (blue ink preferred) Paper: 8½ X 11, printed double-sided, single spaced, on 100% post consumer fiber Stapled, not bound: upper left-hand corner Font: Comparable to 12 pt. Times New Roman Addressed to the appropriate mailing address of the CIWMB Tire-Derived Product Grant Program – TDP7 (FY 2008/09) 9