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Form I — APPLICATION FOR ADMISSIBILITY ENERGY EFFICIENCY: IMPLEMENTATION INCENTIVES PROGRAM Section 1 – Customer identification * Mandatory fields ADDRESS OF PROJECT* FACILITIES AND CUSTOMER IDENTIFICATION Location of facilities * Name of company: * Gaz Métro Account No.: - New building - * Québec enterprise number (NEQ)(Enterprise Register): * Service address: * Municipality: * Postal code: * Contact person: * Title: Building’s owner: * Postal address: * Tel.: Fax: * E-mail: * Financial assistance should be sent to: billing address or Communications requested by mail or address of contact person Communications requested by e-mail** * If the facilities or buildings have different Gaz Métro account numbers, submit a separate request for financial assistance for each Gaz Métro account number. ** Communications may include personal information in the legal sense of the word. IDENTIFICATION OF FIRM/ENGINEER * Name of company: * Person responsible (or measures analyzed by): * OIQ No.: * Postal address: * Tel.: Fax: * E-mail: Section 2 – Description of the building, energy systems and consumption DESCRIPTION OF ENERGY SYSTEMS TYPE OF SYSTEM CONSUMPTION ENERGY SOURCE > (INDICATE CODE) Domestic hot water: Process: † A simulated reference base may only be used for an energy simulation. REFERENCE BASE = 12 MONTHS’ CONSUMPTION to Units Electricity: kWh Oil: litres Natural gas: m3 Dual energy: Other: reference base† E .......... electricity O ......... oil DE ....... dual energy (specify) P . ........ propane NG ...... natural gas O ......... other (specify) Ventilation: source ........ Simulated Code Heating: Period from energy Quantity ........ Actual or Form IIb — REQUEST FOR FINANCIAL ASSISTANCE ENERGY EFFICIENCY: IMPLEMENTATION INCENTIVES PROGRAM * Mandatory fields IMPLEMENTATION INCENTIVES The undersigned, the customer, hereby wishes to advise Gaz Métro of his intention to implement the energy efficiency measure(s) described in the “Summary of measures covered by request for financial assistance” (Form III) that accompanies this request. The customer also includes with this request a complete copy of the Feasibility Study1, which describes the measure covered by the eligibility application, as well as all the calculation papers that help establish the energy savings, signed by the engineer in charge. The customer acknowledges having received and read a copy of the admissibility criteria and all the conditions of the program, as described in the Participant’s Guide, and confirms that he has complied with all the said conditions. The customer would first like Gaz Métro to approve his admissibility for the Implementation Incentives Programs. The customer hereby authorizes Gaz Métro’s designated representative to perform an onsite inspection of the implementation and compliance of the measures covered by the financial assistance received from Gaz Métro. The customer acknowledges that this inspection made be made at anytime within two working days’s notice. 1. Except for the studies covered by Gaz Métro’s Feasibility Studies Program. The customer declares that the information provided in all the documents submitted in connection with his participation in these programs is accurate and complete. The customer agrees that Gaz Métro may check with other organizations likely to be participating financially in this project and to share information with them. The customer acknowledges that any false declaration may lead to a full repayment of the financial assistance paid by Gaz Métro. * Has the work been completed? Yes No * Name of customer’s company: * Name of customer’s contact person: * Title * Date: (day / month / year) Form III — SUMMARY OF MEASURES COVERED BY THE REQUEST FOR FINANCIAL ASSISTANCE - Preliminary Version (after the work) energyeFFiciency:iMPLeMentationincentiVesPrograM Reserved for use by Gaz Métro Price of natural gas Average of the last 12 months: __________$/m3 Description of the measure or scenario, with reference to the number of the measure, as shown in the feasibility study PE N Please complete the blank boxes outlined in blue Useful life Intended final use1 Energy source Energy unit of measure (kWh, m3 or litres) o Annual consumption of measure before implementation (baseline) * Mandatory fields Annual savings (m3) Annual savings3 ($) Costs of measure2 ($) Payback period3 DATECH Total 1- Specify intended final use of measure: process, combined, space heating, domestic hot water. 2- Costs of acquisition, installation, removal, etc. 3- Simple payback period, excluding variations in energy prices. Customer authorization: I hereby authorize Gaz Métro to use the information in this report for monitoring and evaluation purposes. This information will remain strictly confidential. Validation by engineer: I certify that the calculations of energy savings are accurate and that the measures studied and/or implemented comply with the laws and regulations applicable in Québec. * Name of customer’s company: * Validation conducted by: * Name of customer’s contact person: * Name of firm: * Date: (day /month /year) * Title: * Date: (day/month/year) * Gaz Métro Account No: - By e-mail: [email protected] SEND - By mail: Energy Efficiency Programs Gaz Métro 1717 du Havre Montréal (Québec) H2K 2X3 By fax: 514 598-3700 PRINT * OIQ no: