Form - Public Sites – Clean & Prosperous Washington

Site name

Provide site name, Ex. Winthrop Red Apple.

Partner / Name of Site Proposer:

Property manager/municipality/tribe

Location

Address Line 1

Address Line 2

City

State

Zip Code

Legal Owner Contact

Name, phone, email for legal owner

Name (copy)

First

Last

Phone

Email

Legal Owner Support?

Has the legal owner agreed to the charger installation and willing to attest to supporting this project? Yes/No

Site Contact Person

Name, phone, email of person managing the installation (lead applicant)

Name

First

Last

Phone (copy)

Email (copy)

Operational Hours

Note operational hours and any other restrictions

Number of L2 Ports

Total number of ports that applicant is seeking funding for (Maximum allowable ports (20)

L2 Port Connector Type

All sites must have either J1772 or NACS

Number of DCFC Ports

Total number of ports that applicant is seeking funding for (Maximum allowable ports (6)

DCFC Port Connector Type

All sites must have either CCS or NACS

Total # of DCFC Chargers at site

Total number of DCFC chargers at site.

# of parking spaces at site

Number of total parking spaces at site

# of L2 EV Parking spaces at site

Number of L2 EV parking spaces to be installed

# of DCFC EV Parking spaces at site

Number of DCFC EV parking spaces to be installed

Commitment Apprenticeship Labor

Project Labor Agreement

Future-Proofing Adder – Number of stubs outs Per EV Ready Parking Spot:

Number of stub-outs for Level 2

Future-Proofing Adder – DCFC Per EV Ready Parking Spot

Number of stub-outs for DCFC

Public Site Type Application

Level 2 Chargers & DC Fast Chargers Eligible