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2006 Commercial /Industrial <br />New and Retrofit Premium Efficiency Motor Rebate Application <br />Elk River ~ Elk River Municipal Utilities <br />Municipal Utilities 13069 Orono Parkaway <br />Elk River, MN 55330 <br />Business Name: <br />Mailing Address: <br />City, State, ZIP <br />Installation Address: <br />(if different from mailing) <br />Account Number: <br />Phone: <br />Contact Name: Phone: <br />E-mall address: <br />The undersigned does hereby certify that 1. The undersigned, and not Elk River Municipal Utilities is solely responsible for the accuracy of <br />information contained in this appliption, 2. All rules of this Premium Efficiency Motor rebate program have been followed, and 3. the <br />installation is complete. Further, the undersigned acknowledges that nothing contained in the application shall impose any liability on Elk River <br />Municipal Utilities for the work performed and information presented for this program by the customer's engineer, contractor or vendor. <br />Customer Signature: Date: <br />~~- •- • <br />Vendor Name: <br />Mailing Address: <br />City, State, ZIP <br />Vendor Contact Name Phone: <br />• •- ~ <br />End Use ~ <br />Motor <br />ODP/TEFC <br />RPM •- • <br />Manufacturer <br />Model d <br />Nomina) <br />Elf. % <br />Operating <br />Hrs/Yr <br />QTY <br />HP (ea) s10/HP Motor <br />Rebate <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br /> $10.00 $ - <br />"Total Project Cost $ - To tal Rebate $ <br /> <br />End Use Motor <br />ooPrrEFC RPM Manufacturer <br />Model * Nominal <br />Eff. % Operating <br />Hrs/Yr QTY HP (ea) 520/HP Motor <br />Rebate <br /> $20.00 $ - <br /> $2a.oo $ - <br /> $20.00 $ - <br /> $20.00 $ - <br /> $20.00 $ - <br /> $20.00 $ - <br /> $20.00 $ - <br /> $20.00 $ - <br /> $20.00 $ - <br />"Total Project Cost $ - Total Rebate $ <br />vvr - open vrip moor <br />TEFC -Totally Encbsed Fan Cooled <br />`"Reouired Information. The rebate amount shall be limited to 50°ro of the oroiect cost up to $10 000 or as determined by ERMU <br />The Elk River Municpal Utilities retains the right to make adjustments to correct incentive calculations if necessary. Energy savings <br />calculations are estimates and may vary from actual results. Also see 'New Premium Efficiency Motor Rebate Rules and Guidelines'. <br />Important: A copy of this completed application form and Invoice(s) is required before ERMU will issue rebates. <br />Utility Representative: Date: <br />This space for Great River Energy Ilse Only <br />GRE Key Account Representative: Date: <br />GRE Account Code: 10550-912180-0000 <br />2 of 2 2005 New and Retrofit Premium Efficiency Motor Rebate Application 110104 GRE <br />