First and Last Name

Mailing Address City State Zip Code

Device Address (If dierent from above) City State Zip Code

Primary Phone (required)

Applicant Status (check one)

E-mail Address

APPLICANT INFORMATION DEVICE INFORMATION

( )

Old Device Type (check one)

Certied insert Open-hearth replace

Non-certied insert Wood-burning rebox

Freestanding certied stove

Freestanding non-certied stove

Certied insert

Non-certied insert

Freestanding certied stove

Freestanding non-certied stove

New Device Type (check one)

Certied insert Insert

Freestanding stove

Fireplace (Make and Model Required)

Make:

Model:

Freestanding certied stove

* New certied wood or pellet devices must be identied on the list of EPA Certied Wood 

 Heaters to be eligible for funding.

Certied insert

Freestanding certied stove

Wood* Pellet* Gas

Wood Pellet Other

Project # DISTRICT 

USE ONLY __________________________________________________________ ____ /____ /____

Reviewed by

Device County (check one)

San Joaquin Stanislaus Merced Madera Fresno Kings Tulare Kern (SJV portion)

Version 12/2014

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)

Standard Application: Up to $1000* Low-income Application: Up to $2500* 

(Additional documentation required, 

see guidelines)

I am a tenant purchasing for “Device 

Address” above. (Additional documentation 

required, see guidelines)

3. Is the change-out required by District, state or federal 

 rules in preparation for the sale of the house?

2. Does the house have access to 

 piped natural gas or propane?

1. Is the old device the primary 

 source of heating for the house?

Yes No Yes No Yes No

* Receive up to an additional $500 for

 installation costs on a gas device.

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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 nal invoice as ‘refundable’. Review voucher guidelines at www.valleyair.org/burncleaner.

Estimated Wood or Pellet Usage of Old Device (required)

or Cords of wood or pounds of pellets per year: Logs of wood or pounds of pellets per day: Average annual days used:

Questions (required)
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: 

• 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 replace at the device address specied 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 

AGREE & CERTIFY

address. Check one below:

CHECKLIST - Phase 1

________________________________________ ____________________________________________ ______________

Printed Name Signature (electronic signatures not accepted) Date

Project #

You are almost done!

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.

Please submit the following for consideration:

When complete, please print and sign this form, then mail, 

scan & email or fax to the Valley Air District:

E-MAIL: weberip@valleyair.org 

 (Email subject line must show your name and device address)

FAX: (559) 230 - 6112 (Faxed photos are not accepted)

MAIL: San Joaquin Valley Air Pollution Control District

 Attention: Burn Cleaner Program Sta

 1990 East Gettysburg Ave., Fresno, CA 93726-0244

I have included the two pre-installation 

photos with this application (faxed 

photos not accepted).

I will email the two pre-installation 

photos to weberip@valleyair.org.

Subject line must include name

and device address.

I will request the retailer identied above 

to take the two pre-installation photos 

and submit them to the District. 

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

RETAILER INFO

Projected Installation Date: ___________________

Version 12/2014

Register Your New Device! 

Take advantage of more burn days by registering your new certied 

wood or pellet device at www.valleyair.org/CBYBregistration. 

(Does not apply to gas devices)

PHOTO SAMPLES 

(Please see photo 

guidelines at 

www.valleyair.org/

burncleaner.)

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