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 AddressAPPLICANT INFORMATIONDEVICE INFORMATION 

## ( )

Old Device Type (check one) Open-hearth replace Certied insert 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) Insert Certied 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.

Page 1 of 2 

# 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 address. Check one below:AGREE & CERTIFYCHECKLIST - 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 RepresentativeRETAILER 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 .) Page 2 of 2