VOUCHER APPLICATION - Phase 1 Do not make any non-refundable payments to the retailer or install your new device before receiving a voucher from the District. Only refundable deposits are allowed prior to voucher approval and the amount must be clearly noted on the final invoice as ‘refundable’. Review voucher guidelines at www.valleyair.org/burncleaner. APPLICANT INFORMATION First and Last Name Mailing Address City State Zip Code Device Address (If different from above) City State Zip Code Device County (check one) San Joaquin Stanislaus Merced Madera Kings Tulare Kern (SJV portion) E-mail Address Primary Phone (required) ( Fresno ) Applicant Status (check one) I am the homeowner purchasing for my residence at “Device Address”above. I am the property owner purchasing for “Device Address” above. Application Type (check one) Low-income Application: Up to $2500* (Additional documentation required, see guidelines) Estimated Wood or Pellet Usage of Old Device (required) * Receive up to an additional $500 for installation costs on a gas device. Standard Application: Up to $1000* Cords of wood or pounds of pellets per year: Logs of wood or pounds of pellets per day: or I am a tenant purchasing for “Device Address” above. (Additional documentation required, see guidelines) Average annual days used: DEVICE INFORMATION Old Device Type (check one) Wood Pellet Other Certified insert Non-certified insert Freestanding certified stove Freestanding non-certified stove Certified insert Non-certified insert Freestanding certified stove Freestanding non-certified stove Open-hearth fireplace Wood-burning firebox New Device Type (check one) Wood* Certified insert Freestanding certified stove Pellet* Gas Insert Freestanding stove Fireplace (Make and Model Required) Certified insert Freestanding certified stove * New certified wood or pellet devices must be identified on the list of EPA Certified Wood Heaters to be eligible for funding. Make: Model: Questions (required) 1. Is the old device the primary source of heating for the house? Yes DISTRICT USE ONLY Version 12/2014 No 2. Does the house have access to piped natural gas or propane? Yes No 3. Is the change-out required by District, state or federal rules in preparation for the sale of the house? Yes No Project # __________________________________________________________ ____ /____ /____ Reviewed by Page 1 of 2 RETAILER INFO Applicants may visit any retailer participating in the Burn Cleaner program and are not required to choose a retailer at the time of application. A list of participating retailers is available at www.valleyair.org/burncleaner. If you have already chosen and contacted a retailer, please provide their information below (you may still choose any retailer on the list): Retailer Name Sales Representative Projected Installation Date: ___________________ By signing this application, I certify that I have read, understand and will adhere to the Burn Cleaner Program Voucher Guidelines and agree to all of the following: AGREE & CERTIFY • I understand that submission of the voucher application does not guarantee incentive funding for the new device that I am applying for on this voucher application. • I have not made any non-refundable payments towards the purchase of the new device and will not install the new device until I have received an approved voucher from the District. • I will be removing an operable old device or modifying an open hearth fireplace at the device address specified on this voucher application. All wood and pellet inserts/stoves replaced through the Burn Cleaner Program must be rendered permanently inoperable. If applicable, I agree to surrender my old wood or pellet inserts/stoves at a licensed recycling/dismantling facility or to the participating retailer to dispose of at a licensed recycling/dismantling facility within 60 days of installation of the new device. • I understand that it is my responsibility to read the photo guidelines and ensure that the proper pre-installation and post-installation photographs are taken in order to qualify for the Burn Cleaner Program. The photos must be labeled with the applicant’s name and address. Check one below: I will request the retailer identified above I have included the two pre-installation I will email the two pre-installation to take the two pre-installation photos photos with this application (faxed photos to [email protected]. and submit them to the District. photos not accepted). Subject line must include name and device address. ________________________________________ ____________________________________________ ______________ CHECKLIST - Phase 1 Printed Name Signature (electronic signatures not accepted) You are almost done! Please submit the following for consideration: Signed and completed Voucher Application Two Pre-installation photos (samples below) If applicable, Low-Income Documents (See Guidelines for additional documents required) If applicable, Standard Tenant Documents (See Guidelines for additional documents required) Check box if you prefer to be emailed any approved voucher(s) via the email address provided on this application. PHOTO SAMPLES (Please see photo guidelines at www.valleyair.org/ burncleaner.) Version 12/2014 Date When complete, please print and sign this form, then mail, scan & email or fax to the Valley Air District: MAIL: San Joaquin Valley Air Pollution Control District Attention: Burn Cleaner Program Staff 1990 East Gettysburg Ave., Fresno, CA 93726-0244 E-MAIL: [email protected] (Email subject line must show your name and device address) FAX: (559) 230 - 6112 (Faxed photos are not accepted) Register Your New Device! Take advantage of more burn days by registering your new certified wood or pellet device at www.valleyair.org/CBYBregistration. (Does not apply to gas devices) Project # Page 2 of 2