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Contract - TCEQ Grant Application - 6/10/2021Governmental Alternative Fuel Fleet Grant Program (GAFF) Project Application Form TCEQ-20908 Solicitation No. 582-21-22544 A Pli(.)GRAM OF" TGEV Eligible Areas: Grants under this solicitation are available statewide but priority is given to projects in a nonattainment area or in an affected county. Refer to Appendix A for a map of the nonattainment and affected counties for this Request for Grant Applications (RFGA). Nonattainment Areas: Dallas -Fort Worth Area: Collin, Dallas, Denton, Ellis, Henderson, Hood, Hunt, Johnson, Kaufman, Parker, Rockwall, Tarrant, and Wise Counties El Paso Area: El Paso County Houston-Galveston-Brazoria Area: Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Wailer Counties San Antonio Area: Bexar County Affected Counties: Bastrop, Caldwell, Comal, Ellis, Gregg, Guadalupe, Harrison, Hays, Henderson, Hood, Hunt, Johnson, Kaufman, Nueces, Parker, Rockwall, Rusk, San Patricio, Smith, Travis, Upshur, Williamson, and Wilson Counties Eligible Applicants: Eligible applicants include state agencies, counties, municipalities, school districts, junior college districts, river authorities, water districts or other special districts, or other political subdivisions created under the constitution or a statute of this state that operate a fleet of more than 15 motor vehicles, including a mass transit or school transportation provider or other public entity established to provide public or school transportation services, but excluding motor vehicles that are owned and operated by a private company or other third party under contract with the entity. Eligible Activities: Eligible activities include the purchase or lease of new alternative fuel or hybrid vehicles and refueling infrastructure and services for those vehicles. Application Deadline: Applications will be accepted on a competitive basis until 12:00 a.m. CT on June 15, 2021. Applications may be submitted via TERP Online, electronic mail to TER Papply(d)tceg.texas. gov, or by mail to one of the addresses below: Regular Post Delivery Texas Commission on Environmental Quality Air Grants Division, MC-204 P.O. Box 13087 Austin, Texas 78711-3087 t-.o-2bal ---o i!�� Express Delivery Texas Commission on Environmental Quality Air Grants Division, MC-204 12100 Park 35 Circle Building F, 1st Floor, Room 1301 Austin, Texas 78753 Form 1.a Applicant Inforiveation 1. applicant Legal Name 2. Business I�ormatlon City of Round Rock 3. Authorized Official The aDDIcant or an employee who has legal too sign for and speak on behgg%"v of the eMitY. 4. [Designated Ptject ftprmwntative Tho aodir�nt or an employee who will serve as the poInt of aontad for this applicau(miLno So D9Wgnated LOCWon fog Reconls Ae..cess and Review bY the TCEQ or Its Repm"ntative Please Provide the physical address where records relating to this project may be aid and reviewed. FY21 Govemmented ARemadve, Fuel Fleet Grant Program TCECI=20W8 (Version 21 .01) Form 2: Third -Party PropAIarer Signature Page Is Was this application prepared by a tltIrd-party4 q thirdparty preparer Is someone who is essistlng in the preparation of the grant appl*ca�on, but who is not reletted to w a cuffent employee of the applimnL OY" RNo 2. Third -Party Pmparer Cemficdlone I hereby MR tify that, to the best of my Iv�wledgs and belief, atl t�ormatlon provided in this appttcaUon and arty attachmentss true and oomect� as repmMMIUM�to me by the applica�. I understand that failure to sin ft app1hmtbn or signing it wfth a false ststert�ent may make the banded otter or any re"ng ts voidable. Thirderly PfleDgrer 111fOflllone "Please OHu.##e enure application before completing theelecto nic signawfe. i im aun" w cuN acid, or remove Informagon W11 be removed after the applicatlon is etec�ronk;ally signed• Is PI - TCEC)r20908 (VemW 21 .01 Fy2j Govemmental Ajt emaWe Fuel Fleet Grant Prog Form 3: Program Certifications This section serves to assure the TCEQ that you understand and agree to the statements below. These provisions relate to the basic contract document which will be in force between the applicant and the TCEQ upon award of a grant. TCEQ urges applicants to download a copy of the example grant contract from www.terpgrants.org and review it so that any questions can be discussed early in the application review process. BY signing ning this application, you understand and certify compliance with all the statements below, as well as with any state statutes , re ulationspolicies, guidelines, and requirements as they relate to the application, acceptance, and use of funds for this g Project. If of these certifications change between submittal of the application and award of a contract, you will 1 any promptly notify TCEQ. Activity Certifications 1. Use of Funds. A licants must rioritize the followin activities when usingrant funds. A licants must indicate their riorit activity by checking one of the boxes below. FE-1 The purchase or lease of new motor vehicles, including new motor vehicles that are converted to operate on an alternative fuel, when replacing vehicles or adding vehicles to the fleet. The purchase of new motor vehicles, including new motor vehicles that are converted to operate on an alternative fuel, to replace vehicles that have the highest total mileage and do not use an alternative fuel. To the extent feasible, obtaining, whether by purchase, purchase and conversion, or lease, motor vehicles that use Compressed Natural Gas (CNG), Liquefied Natural Gas (LNG), or Liquefied Petroleum Gas (LPG). 2. Destruction Required for Replacement Projects. For replacement activities, the grantee must provide verification to the TCEQ q P that an existing vehicle of the same type has been destroyed. In general, vehicles being replaced, including the engine. must be destroyed within90 days of receiving verification from the TCEQ that the proof of purchase documentation for the grant funded y 9 vehicles has been approved. 3. Not Otherwise Required. To the best of the applicant's knowledge, the proposed activities are not required by any state or federal law, rule or regulation, memorandum of agreement, or other legally binding contract. 4. No Emissions Reductions Cred its. Activities funded under this program are not eligible to generate marketable credits under state or federal emissions r reduction credit averaging, banking, or trading programs. If the project is funded, the applicant waives, for e all time, its right to clam or apply an I for emissions reduction credits from the use of the low -emission technology funded under this Y program. ° of E ui ment Cost. Any existing financial incentive that directly reduces the cost of the proposed activity. 5. Not to Exceed 100 /o q p r deductions, other rants, or any other public financial assistance must be disclosed at the time proof of such as tax credits o d 9 purchase documentation is provided to the TCEQ. The total grant amount plus financial incentives must not exceed the total eligible cost of the project. 6. Failure to comply I with certain contractual terms may require the grantee to return all or a share of the grant funds. Grantees will be required to maintain the grant -funded vehicles in proper operating condition and to obtain sufficient replacement insurance to repair or replace the vehicles if they are damaged or destroyed during the Contract Period. Grantees must agree to notify the TCEQ o any f n termination of use, change in use, sale, transfer, or accidental or Intentional destruction of grant -funded vehicle s duringthe Contract Period. Grantees will be required to return all, or a pro-rata share of the grant funds for failure to maintain and operate the vehicles for the duration of the Contract Period. 7. Requirement to Monitor. Grantees will not be required to submit annual reports on the use of the grant -funded vehicles and equipment. However, the grantee must agree to provide information on the use of the vehicles upon request by the TCEQ. The grant must also agree to provide the TCEQ and/or the State Auditor, or their representatives, access to the vehicles and to ee g records regarding use of the vehicles. 8. Insurance Coverage. Grantees must maintain, for the Contract Period, property loss insurance or self-insurance coverage on vehicle and/orequipment acquired, leased, repowered, retrofitted, or constructed using these funds, sufficient to cover the any eh cle costs of reimbursing the state for its pro -rats share of the vehicle or equipment costs. 9. Legal Authy applicant Authority. The a licant has the legal authority in the State of Texas to apply for the grant. The applicant's governing body has au thorized the filing of the application, understands these requirements and certifications, and has authorized the person identified as the Authorized Official to act in connection with the application and to provide such additional information as may be required. Administrative and State Contracting Certifications I. Uniform Grant Management Standards. The applicant will comply with the Uniform Grant Management Standards (UGMS), adopted Juney 2004 b the Texas Comptroller of Public Accounts in accordance with Texas Government Code Chapter 783, or any q P subsequent update. This document is available at: http llwww comptroller texas govlpurchasinq/docs/ugms.pdf. FY21 Governmenta l Alternative Fuel Fleet Grant Program TCEQ-20908 (Version 21.01) 2.Procurellient of Q�Aods and Services. In Fucu�irt9 Soods and .the sPpl�ant w81 canpiy with UGMS Part ill. Stale Uniform Adlnmuwn`va Kequire"Mrts fog Granbs. _ 36 Procurement. AN Pa.Aurement transactions win be nd AeA In a manner p�d�►9 fun artd OW comPeti�n. Hkdwwally Undemdlmed Businesses (HUBS). Quall1lou Husso � defln� and designated under sbabe taw, shall have the Emu predicable opport�ity to paf0dpete in tt�elormenoe of the work arising out of Vft eject. 4. NanMNFA MInadom The apol wig mpy with al State and Federal9& MMW tn relating to nondl9climInadons v. Grant Adm1nN`W*Wation. The appilcant wW maintain an approP�W grant administrntlon system to ensureSU tenns, conaRkwo, find speaIRMor�s of the grant, inducting these oertlHHcatlons end uranoes, are met. Go Audit Aooepmnce of funds under thk program acts as a roe of the authority of the State Auditor's Office, or any fil�ooessar agertcy� b oondud an audk or irnre�lge�on to c�nedia� with those lands. The applicant or other madly that may rec�ehre turMs directly or Indfrectl�► from TCEQ met provide the state auc� witlt aooess to any b�fan�etion the state �di6or cor�tders relevant in the Inve0gadw or 81.d� ABM will ir�l�e this cause canceming the authority to audit tends received hwilecdy and the requirement to mete in any subcontract It awards. To Deft io the State. The applk=IL is not indebted to the state or has an outstanding tax "Inquency. The appllwnt must comply with all State and Federal tax laws and fee requi is and Is edelY resPonable for fling all Ste,.,,. and Federal tax arM fee fonvla* L Debarmento The apolcarrt oerdfies that the aPPWg entity and its PrindpalsHdpate in thistranssc�lon and are eligible to par have rid been subjecled bo sUsPW=Rn1q debeRnent, or similar InO1191b8ty deWmrtined by any federal, state or focal governmoliw en*. L ConfDA of 115MISst. The appiEcaM has not ghren. offered to give. nor intends to give any 8=10Mic opportunity future emptoymen� gift, low� 9�ft,specW dw.-oourtt� trip. favor. or service bo a pubic ssrvaM to oonnedion wiTh the submi�ed ail n. Una TexasGovernment Code Sectlon 2155.004. no Person involved In the K"aWARtof the Request fbr Grant ne may hm'onanaal inte�at In 11� applk. M the appli�nt IS not ellgible, then any contract resu�tng fran Is ap�l shah be IrnmediaRely termMated. FuAhertnore, under Teocas GovemmeM Code Sectlon 2165*004o ft aPPIlCant cerdfles that the In Mdual or business amity Warned in 8P1 n is ot InaloWe to receive tl�e spedfled contract and edmvwlstlg� tl�at the contract may be fierminabed. and payment w{thh�d If this cerdflc�on is insxurats. All purchase dedeb� must be on sound n d arld arm's length bargaining. I0. Codulacting wkh an Ex�utive of a Stale Agent. Under Texas Govemlr�ent Code.,.....eclion 869.003. rWadng bo contractlng with an executive head of a e agenoY� the Pplicant represents that rro person who. in the past four years, ssrved as an xecutive of the TCEQ or any a�her state agency. was involved with or F�as any interest inS thk app6cati�on. If applicant employs or has used the services of a former mve head of TCEQ or other stake agency. the applicant sheR p�rovtde the fol bwing 1nW.1Rt0n: name of former execxitive. name of state agency date of seperatlon from state agsncY, Positlon with a nt and dale of employment with ant I 1. Under Tenas GovernIgM,nt Code Sedan 2155.OQ6, the appl�ant cetfities that "I ndividual or business entity namsd in this n is noIneligible togaceive the spedfled oorotrad ed A ges that any centred resultlng from Vft appIcadon may be fierminebed and payment withhold N this cerHQcatlon is insxurate. IL The appUcaM hasrot been adjudkmLow during the three-year period Imm...iat�y the apptic�Ion sEgnaturedateIng to have committed flubstaMNe. nonadedcel vidat�ns resuldng In an ac�usl release of hazardous waste that presented an Imminent and substeMiei danger to the publ(c hesRh and safety or the environment, 113o The ap�lic�nt. nor any of ibe officers. have been adjudtcated by a court of law to have vblated the Texas Deoeptive Trade P Ad. 14L Abortion Funding UmItstion. The applicant represents and wwmnts that any payments made by TCEQ wM appropriated fufug.ntam should a contract be awarded. not proMbRed by AArtieOa&ction 625 of the GeneralAppropiatlona Ad, 86th LegisisNve S�slon I nor by Texas Gon ment CodeC r 22.88th l,.egielative Session (2019)). 1g� ed parges. Appticent represents and warrants that R Is not listed in the prohibited vendors lkft auftIELffad by Executive Order No. 13224� 'Btocicing Plaftank,perty and Prohlbfflng Transactlo� with Pe rsons Who Comm, Threaten to Comma,or Support Tortariem: Published by the United Stales Deprtment of tl�e Treasury Office of Foreign AAssetsControl. Appikent wM notHy T CM if ft can no longer make this Mi don. Mi Gove me I AltemaVve Fuel Fleet Grant Program Ei0im20908 (Version 21.01) Form 4.a Certification of Eligibility to Receveia State -Funded Grant Aq apptic�Ms must complete fhk form to ce�ttiy elEgibgit�l tO reoeNO fak grant Under this Pro9ram� regardless if child support oblWadm bo the appapplicanttc�Faflure t� submit th(s formLPN mayAMARL AML Ahdt to rejqmwk%,W%p of the application. CartlAcatton Regarding Child Support Obligatlona Under Sin 231.006, Texas Fam4..~4e a childmspport obl%W who Is more than 30 days delinquent In payln9 child support ar�d a lwsiness entity in which the obflgor is a sole Pry. Parater� shsrel�tdder� or owner with an o�nrn�iP tnberest of at least 25%918 tit 61191we to receive a atate�unded glMlt or loan. All epplIcents must indude In the aason the name and modal s�urity number of the individual or sde proprkdDr and each partner. shareholder. or owner witl► an awme�ship interest d 25% of the bins endtYsubm2n "V the apron. FEDERAL PRIVACY ACT NOTICE: This natloe Is givenpurswnt to the Federal PdvaW AdDISCIGG ore of your Sodal Sec^11ftg%ANumber (SSNj is required w� Sectlon 231.006(c) and Sectlon 231.302(c�2) of the Texas FamNy Cede. The SSN w10 be tp Idly pennons that nay owe child suppolt The SSN wiU be kept o�e�Bal to the fuRest ex�erd Mowed under Sectbn 231.2o), Texas Famlr Code. Please Check One of the Following Applicant Options. if OPOOnI or 2 is checked, list the nM 9(9) and social security numbers) (SSN) belAM. NaAMW* sochd Sewrky Number (88Nj: Name: al Number Name: Social Security Number (88N): Name: Sodal Security Number Name: Soe�al 8ecurtt�► Number ce�tQy that to the best of my knowledge and belief that the individual or business MiL" submktlng this application Is eligible �o Mceive a grant.I ack"WW1edge that the grant contract may be terminateand anY MN Y�ets withheld it this oaAtlH -tlon Is tnsccura�e. 'PEease flfl out the entire I Mon before completing the ele nic signature. The abfllty to ed1% acid, or remove infomre�don wfll be removed afte r the applumtlon is ekodwnfcepy signed. FY21 Governm Aftemative Fuel Fleet Grant Program TCE(.1-20908 (Version 21.01) For 5: Vehicle Information Activity No. 1 �WW Click here for additional blank pages +❑ 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type.e Class 1 Vehicle (GVWR up to 6,000) Q� Fuel Type: Electricity 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. Vehicle Types. Class 1 Vehicle (GVWR up to 6,000) Q Vehicle Model Year: 2010 Fue I Type: Gasoline Q 3. Requested Grant Amount. Please select the grant amount from the drop -down menu,. ---- ------ Grant Amount: 1$15,000 (Class 1 Vehicles) a Activity No. 2 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type: Electricity Q 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providinginformation below. Vehicle Type: � Class 1 Vehicle (GVWR up to 6,000) Q� Vehicle Model Year: 1 2004 Fuel Type: Gasoline Q 3. Requested Grant Amount. Please select the grant amount from the drop -down menu. Grant Amount: 1$15,000 (Class 1 Vehicles) �I Activity No. 3 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) FZI Fuel Type: Electricity 0 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. 3. Requested Grant Amount,, Please select the grant amount from the drop -down menu. Grant Amount: $15,000 (Class 1 Vehicles) �I FY21 Governmental Alternative Fuel Fleet Grant Program TCEQ-20908 (Version 21.01) Click here for additional blank pages �+ Form 51, Vehicle Information Activity No,. 4 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type: Electricity 0 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be dPstroved bV Drovidina information below. 'low Vehicle Type---m : Class 1 Vehicle (GVWR up to 6,000) [Ell Vehicle Model Year: 2002 Fuel Type.: Gasoline 0 3. Requested Grant Amount. Please select the grant amount from the drop -down menu. Grant Amount: $15 000 (Class 1 Vehicles) D Activity No. 5 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle,. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type:: Electricity 2,* Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. -- U 3. Requested Grant Amount,* Please select the grant amount from the drop -down menu. Grant Amount: 1$15,000 (Class 1 Vehicles) Activity Na 6 I. New Vehicle Infoation. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. I Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type: Electricity Old Vehicle Information (Replacement Activities Only). destroyed by providing information below. The applicant acknowledges that the old vehicle must be 3. Requested Grant Amount,* Please select the grant amount from the drop -down menu. Grant Amount: $15,000 (Class 1 Vehicles) f FY21 Governmental Alternative Fuel Fleet Grant Program TCEQ-w20908 (Version 21 .01) Click here for add'oItional blank pagesE I Form 58 Vehicle Information Activity No. 7 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle GVWR up to 6,000) Q Fuel Type: Electricity Q 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. 3. Requested Grant Amount. Please select the grant amount from the drop -down menu. Grant Amount: $15,000 (Class 1 Vehicles) a Activity No. 8 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle., Vehicle TypeeClass 1 Vehicle (GVWR up to 6,000) [�] Fuel Type: Electricity 0 2. Old Vehicle Information (Replacement Activities Only). destroyed by providing information below. The applicant acknowledges that the old vehicle must be 3. Requested Grant Amount. Please select the grant amount from the drop -down menu. Grant Amount: $15,000 (Class 1 Vehicles) El Activity No. 9 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type: Electricity 0 2. Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. 3. Requested Grant Amount. Please select the grant amount from the drop -down menu. Grant Amount: $15,000 (Class 1 Vehicles) • FY21 Governmental Alternative Fuel Fleet Grant Program TCEQw20.9-08 (Version 21,.01) Click here for additional blank pages 1- +1 For 5: Vehicle Information Activity No. 10 wmp� 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. 2. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Fuel Type: Electricity 0 Old Vehicle Information (Replacement Activities Only). destroyed by providing information below., The applicant acknowledges that the old vehicle must be 3. Requested Grant Amount Please select the grant amount from the drop -down menu. Grant Amount: Isl 5,000 (Class 1 Vehicles) Activity No. 1. New Vehicle information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000)7 Fuel Type: Electricity 0 Ze Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. 3. Requested Grant Amount. Please select the grant amount from the drop -down menu,. Grant Amount: 1$15,,000 (Class 1 Vehicles) Activity Na 12 1. New Vehicle Information. Please refer to Section 2.3.1 of the Request for Grant Applications for requirements that apply to the purchase or lease of a new motor vehicle. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q 1W Fuel Type: Electricity 2,o Old Vehicle Information (Replacement Activities Only). The applicant acknowledges that the old vehicle must be destroyed by providing information below. Vehicle Type: Class 1 Vehicle (GVWR up to 6,000) Q Vehicle Model Year: 2005 Fuel Type: Gasoline 0 3. Requested Grant Amount. Please select the grant amount from the drop -down menu.. Grant Amount: 1$15,000 (Class 1 Vehicles) El FY21 Governmental Alternative Fuel Fleet Grant Program TCEQ-20908 (Version 21 .01) 'D Form 61: Project Primary Area Applicants must designate a primary area of use for the vehicle(s) included in the project application and provide a percentage of total annual mileage to occur in that area in the table provided below. The primary area of the project is the area where the vehicles) included in the project application operates at least 51010 of its total annual mileage. If the area of operation is not listed in Section 1, provide the primary county 46 in Section 2. Additional counties where the vehicle(s) will be operated may be included in the business description in Section 3. 1 _ Primary Area 2. Primary County of Operation (if not in one of the Primary Areas listed above) Primary County of Operation Percentage of Total Annual Use 3. Description of Use Provide a detailed description of how the vehicle(s) included in the project application will be used in the routine nnPrations of the aoDlicant. In addition, please provide additional areas or counties of operation. These units are used to transport personnel, tools, and equipment from job site to job site and between offices. These unit function primarily within the bounder*ies of the City of Round Rock with occa'tonal trips into Austin/ Travis County to aquire supplies for daily operations. FY21 Governmental Alternative Fuel Fleet Grant Program TCEQ-n20908 (Version 21.01) Form 7: Summary Page Applicant Information. Applicant Legal Name: City of Round Rock Entity ' Applicant Type: Governmental ___ FEI or SSN: 74-6017485 Other Primary Project Area: Austin Area Primary County: 12 Total Requested 162000 Total Number of Activities Grant Amount (vehicles only): (vehicles only): 18000 Infrastructure Type Total Requested Grant Amount (if applicable): (infrastructure only): 221 E. Main St Mailing Address: city: Round Rock state: TX zip code: 78664 How did you hear about Email ' Other this grant program? (please specify): Authorized Official. The applicant or an employee of the applicant who has the legal authority to sign on behalf of the entity. I hereby certify that to the best of my knowledge and belief, all information provided in this application and any attachments is true and correct. I certify that I have read the complete application after all forms and information were completed. I agree with the information provided, and the date provided below is the date I signed the form. I further understand that prior to incorporating these forms and information into a contract the data and information may be revised by the TCEQ for accuracy, and the acceptance of a contract will constitute agreement with those revisions. My signature also constitutes acceptance of the certifications in Form 3, the terms of this grant, and any changes posted through addenda on the Electronic State Business Daily. Failure to sign the application or signing it with an incorrect statement may make the submitted offer or any resulting contracts voidable. Printed Name of Authorized Official: . Craig Morgan Authorized Official Title: Mayor Signature of Authorized Official: Date of Signature: The application, signed by the Authorized Official, must be received by the application deadline or the application will not be accepted. Intentional falsification of these forms will be prosecuted to the extent allowed under the law and may be used as an adverse factor in future grant selection decisions. Upon submission, all proposals become the property of the State of Texas and as such become subject to the Texas Public Information Act, Texas Government Code Chapter 552. Personal Information Policy: Individuals are entitled to request and review their personal information that the agency gathers on its forms. Individuals may also have any errors in their information corrected. To review such information, contact the TCEQ TERP program at TERP6�tcey texas.gov or 1-800-919-TERP (8377). FY21 Governmental Alternative Fuel Fleet Grant Program TCEQ-20908 (Version 21.01) Form 8: Application Checklist All applications require the documents listed below. Please ensure that you have read and attached all of the required documents. All pages that must be signed or initialed are indicated below. If a signature page is missing or has been altered, the application will not be considered. Application Form Checklist (All Applications): Form 1: Applicant Information Please fill out entirely. Form 2: Third -Party Preparer Signature Page If a Third -Party Preparer was used, Signature Required. -- — -- Form 3: Program Certifications Please read, Indicate Priority, and attach with application. Form 4: Certification of Eligibility Signature Required. Form 5: Vehicle Information Please fill out entirely. Print additional pages as needed. Form 6: Project Primary Area Please fill out entirely. Print additional pages as needed. Form 7: Summary Page Please fill out entirely. Signature Required. Form 8: Application Checklist Please read and include with application. Required Attachment Checklist (All Applications): W-9 Form Signature Required. https-://www.irs.clov/i)ub/irs-r)df/fw9.pdf If the Equipment has already been purchased, provide the purchase, lease or financing agreement showing the rice paid. The purchase may not have been made prior to September 1, 2020 Supplemental Forms (if applicable): Supplemental Form 1 (Refueling Infrastructure projects only) Applicants applying for Refueling Infrastructure projects must complete this form and attach it to the application form being submitted. FY21 Governmental Alternative Fuel Fleet Grant Program TCEO-20908 (Version 21.01) UP�Iqmental Form 1—Refueling Infrastructure This fam shag a�dy be cattple�ed by appifcet�s pr�ht8 Pro1� � include the P�dta�e. femme or t on of reh�eling Infi re � eguipme�t. or the proour�ement of r�e�i�elNtg "11rN�. The tease o� rtfit�ng � or refite6r�g services Est be made in oor4wxlon wMh the puke of an aftoaiive fuel vehicle Proposed f� funding under this program. The grant applEcea�t must domonstrate that a wing statlon meeting the needs of the a nt is not wa wilhIn flue mks of the tcc�tbn at wh�h fhe appik�nt's meant -funded vehicle w�l be stored or Prf-ariy used. Leases of neh�g infrashudure or IjX1ent or the procurem�t of refueling services must have a term of at Nast thrm years eo be i0j#We Uor grant funding. 1. Pfajed DesafpUon. In fte sp�oe Provided belowv, ��e Provide a Miof d-..-.�xiptlon of du Ing I�''oj� being proP� IndudIng the fuel type, esdmab� number of vehicles ae�ved bll the rofue�tn9 lr�trastrud�me or equlpn�e� per day. MN or chaMing �dty off ft equipment. and facility hype. N ttre reftefing project would be leased, provide, the proposed temp of OW lone and any plans for On OWdnUW OWn6Mh1P artd Opemflon of the refluelfig lnftilt�n�bure or equipment afterthe berm Of Ale 9Mft ems. To install dedicated charging b�tions to support the 12 electric vehicles we plan to purchasing for the City fleet. Z. Cturent /►cis to Refining In�rasbudure or Equipment In the space below, please provide a descriptlan of the applic�t's cum�t access to refuepng iMrastrucbure or equipment Mduding the distarroe fi� e nearest refueling oA.0ag s�adon that meets the needs of the vehicles Included In the apirr . If refuepng intresfrudure o equipment s cuReMly avaBable In five miles of where the vehicles w0l be siorsd or prinarRy used. ple�e a�la(n why this available iMrastructure or eguiPment dog not meet eeds of the vehicles included In this Puun go - e only recharging locatlon within flue miles of the closest la�ion is at the Round Rock Premium Oust01 No 135, RoundRods TX. This 1ILMUU11 is not Sutable as do not store City vehic�s at this location. S, proposed Refueling lest�astrucWre or Equipnrent Loc�On 4. Pmdroped Thl riy Service Provider IMartnetlon (d aPP�~�) 3erWoe Provider Newsom serviceAddloam Provides Ck County Service Term Ztp e L Reguesbed Grant Amount for Re�elh�g lM�u�tre. EiWlPnrent, or 8ervloes In the space tHdow, please provide the requested amount for refueling infrasducture. equipment, or refueling services. The total requested grarrt amount for refueling proms msy not exceed 1096, of the total requested grant amount for the vehhMMI.A..ft.. Final Payllent W11()Ur�ts rtrey rwt exceed the mtal eligble cost of the project. Refue{Ing Irrfrastrudure. EqU1p1Equipment.Or SOrvioes Req�tesied Grant AAmour3000.00 FY21 Govemmerrtel Aftemative Fuel Fleet Grant Program TCEQ-20908 (Version 21 .01) Supplemental Form I -Refueling I�frasbvcture This tam should DIY be comptebad by aPO___P �Olerts that Indude the puke. lease or instaflatlon of refi�ling h*88trttcture or equipmetrt� or the Procurem�t of re�fuueiing �ervtoes. The pie of refuedn9 ��e or nsfuN'ing servtoes met be ode in oonjundio� with the puke of Win a(temati�re fuel vehic� proposed for funding under this program. The grant appikk�M MIM demo�6'�be that a refining station meetly the needs of On applic�mt is not ava within five miles of the ,Uw at which the applic�nYs grant -funded vehl* vA be atoned orpmg�ily used. Leases of retuning hifi�astructur�e or equipment or fhe Procureme� of �etueli� sew must have a �m of at least tlu+ee years do 1)e eligible for grant funding. 1. Project Description. In the spaoe prcNwed betow� P�Se Provide s brief tlesaiptifln of dale refueling project being ProP� inducting the fuel type, estimated number of vehkv,.W�s senred by' he revuaang Int�tr e � e4u{pms�t per daY� refudft or �'8M9GRIMOSY of the �WlpmetK. and fat�tly t�IPe. Ifthe refueling �ojed would be leased proviae the pwpowdA I IM of the lase and ny plans for the condnued ownership and of refueling I ckre or equipment alter the bum of the grant e�ir'es• To *install dedicaWcharging locations to support tO 12 electric vehid� we plan to pumhasing for the L Current Access to RoTueling Irfisstrudure or Equipment. In the itpsoe below, please pr�+id418 deacrip�on of the ap�k�nYs Curl+ent axes to refuelir� iMrastrudure or equlpmem. inducting the d�tanoe to the nearest refueling or ch�gir� taA��that meetsthe needs of the vehicles inducted in Oft appl Uune If refueling I o UU cWm is cumr►tly avasable within five Mies of where dw vehicles wM be shored or ��u1y used, �§ ^ �y ths "labe I"Dastrucdu+e or equipment does not meet the cunat needs of the veh,"L'ies in�ded in this appdcation.- a The only recherging la�tlon within five miles of the d1"�1=W1WW1WWt locatlon is at the Round Ra�c PMmium Outlet Mall located at 4401 N.135, Round Rods TX. Ths I'Iblmlion is Rot eatable as do not store City v�ides at this on. 8, proposed Ing Infrastru cture or Equlpne'nt Limon 4. Proposed lnd4Paft Service Provider henn is=' on fif aPPMUM i genrice Provider Name Service Provider Address Vitt County Service Tin Zip Code S.lw�§t AmountInfratrcture. Equmt. or SOMCSS In the apace below, please Provide the requested amount for refueling iMrasbucbure, equipment, or refueflng services. The total requested gretrt amount for refueling projects may not exceed 10% of the total requested grant amount for the vehhm. Frud payment amo�trrts �► not enoeed the total eligible cost of Ute project. - Reiueftng h�hastructure, Equipment, or Sevvk�s Requested O�rt Amounts � 3000*00 FY21 Governmen lternative Fuel Fleet Grant Program TCEQlw2O9O8 (Version 21 .01) Supplemental Form 1—Refueling Infrastructure This forrn sh"qW�td only be oom by applh�rns propos�n9 Protects that ind�uie the purchase ke" or Ir�� oT muming b�hastrudure or equtptrter�t. or the procurement of refuedng servloes. The purchase of retueUng Insitemntrudure or rigueling services must be made to cor4uncdon with Me purchase of art atternative fuel veMde proposed for furWing under Oft program. The grant apptk_ - ;aM ma refuenng n meetly the needs of he ap"p om.A sJUL available w1Hnt flue md of tl0 kW AtAn at which the panrs grant -funded veltice w1l be stored or primarily used. Leases of refueling Inastru re o eqUIP1MIL or the POCiremeM of refuel{ng services must have ate of at least three yearffi 10 be epgibte fear grant funding. In Project Description. In ft space provided below. please Pra�ide a brref d�i�ion of the refi�lin9 projW being propom imdudtrrelueNig � 10the fuel type. esdn�ted nwnber of vehl�s served by tlee mfteNng fillsostnwture orequi pmeM per days or chaFUlng capacity af the equipment and kdllty Wir"We If the refining PrOA would be leq..-Seed, provide the PAMbAOed been Of the I9ft& and anyP10nAle continued whip and operation of the wing k u#UCwre or equipment after the AL of #19 giant ems• To It--Om,u dedicated charging kxMfions to pport the 12 electricvehi es wean tO purchasing for the City fleet L Current Access to RelueUng lg9astradure or Equl�nenL In the spaoa below. please provide a descripftnof the aPOfcent's cement access tofuellng I112sbuctue or equipment, including the distance o tto nearest refueling orcha r gi g s�[on meets the As offfie v�idss inducted ln this apPlun"une Ifefuellng infrastructure or equQmn$CU"a& awlable withM flue mM* of where the vehlcNs w1H be stored or primarily used please explain why thb snrapable inirasUucture or equiprtrent does not n et the dement news of the vehicles Inducted to ihis motion. The only recharging location within five rrn'les of the Cmsest Iocation is atM Round Rode Premium Outlet Mail locabed at 4401 Ns 135, Round Rode TX. This 1O0HA"m] is not ble as do not shore City vehicles at this location. 3, p�p�ed R�e1tr� �Mrasducbure or Equipment Irocatlon 4. proposed ThIn�Party service Provider Innnseo �afion (!f epplkablel L Requested areM Amount for Refueling I t I NA ucture. Ipment, or Services In thespace below, please provide the r9qu%PW%%~ amount for retueting tntrestructure, equipment or refueling services. The total UesCed Brant amount fw refueflng projecis aynot exceed 10% of the tptal requested grant amount for the vehid Final payment amounts slay not exceed the to= ONgae cost of the project. Refueling Iwo Equipment, or services Requested grant Amount: � 6000.00 FY21 Gove me I Alte ative Fuel Fleet Grant Program TCE(;1m20908 (Version 21 .01) Sup�ementai Form 1— Refuel ing Infrastructure This fiortn sfiou� only be canple�ed by eD��ar�s Probing Prolec� that include the purchase, lease or I-Fstallatlon of refueling ktastnuclurs or equipment. or the Procurement of refudt� services. The pun�se of refueling inlrastrudure or reMdng 5 hill must be made to oonjuncdon with the putw....e of an attemative tub vehicle p�vpo�ed for fundh�g under this program. The grant appik�nl MUnst demonstrate tltiat a �fueting station Me�Mg the needs of the applk�nt is not avallable wNhIn flue mH� of the kmdon at wh1ch the applIAMSlCs grant -funded vehkA9 w11 be stored or primary used. Leases of r+e�fu�Ing iMrastrucWre or ewipinent or ft procurement of refuelingamrvices Must have a teem of at least three years b be eNgible for gVMdrrt funding. is Project Descrtptlon. In the space provided belo�►� Pteese Provide a brief descxtption of fhe refueling P�1� �in9 pe,�� Im ding the fuel type, estimab�d number of vehicles served by the refueling 11OU-�Uucbure or equiPmentpedays refueling or chargingm ohequipmen%mid fac1ty type. if theefueling Project would be leased provide the proposed teem of the lease and any plans for the continued ownership and operatlon of the refusUng 1-*astructure or equipment after the ie�m of the grant 0)(PhWe To install dedicaW charging locations to support the 12 electric vehicles we plan to purchasing for the L CUr�M Access to RefuelMg 111514MWucture or Equipment in the space below, please Providea deacxip�on of the ap�k�nYs cumeM access to refue�in9 infrastructure M INUlpment� Induding to disianoe to the n1wouest refu�Uig or d�'gin9 station that meets the needs of the vehicles included in this appltcatbn. If refuNir� Inhashucbure or equipment is artmeMly avelable I Ihfive miles of re the vehfticlewill be*MME o11wrIN=seMz , Please explain why this ralable infrastructure or equtprneM des not It the cement needs of the vehicles Included in this ap�icatlon. - - The only recharging locatlon within five mites of the1ocation is at the Round Rods Premium Outlet Mall located �t 4401 N.135. Round Rods TX. This lication is not sutatie as do not store City vehicles at this lon. 3. Propasad RelwUng M91510OWUcbure or Equipment won d. Proposed Thfrd�arty ralkift Service ProvIder IMorn�alton rf a1 9 blsl SeMce ProvWer Name servim Address r►"�J County Service Tenn Steft Zip Code L Robed Grant Amount for Refi�elIng In(�astructure, Equillmu"at or SOM068 In the space below, please provWe the requested amount for refueling I�asbuclure, equipment, or refueling services. The total requeabed grant amount forrefueUng pMects may not exceed 10% of the total requested grant amount for the vehides. Final payment amou may notwraped the dotal e1lgt�e cost of tl�e project. RMtueUng I sstrMWt- re, or Soma"AAaS Grant Amount 000� FY21 Governmental Aftemative Fuel Fleet Grant Program TC Ckm20908 (Verson 2141)