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Multifamily Energy Savings Program EQUIPMENT TUNE-UP WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 Property Name: Installation Address: NATURAL GAS BOILER TUNE-UP Contractor is required to fill out all information for reimbursement. Minimum burner size of 110 MBh. n This incentive is only available once in a 24-month period. n Eligible systems must have a minimum of 1,000 hours of online operation annually.
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Natural gas burner service must improve the combustion efficiency. Contractor must perform before and after combustion efficiency tests and record results.  n All in-house testing must include a printout from the combustion analyzer. n This incentive is only available for HVAC natural gas boilers.
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Boiler 1 Use Equipment make and model: Age: Indoor/outdoor reset: q Yes q No Pre-service combustion efficiency: Pre-service stack temperature: Annual hours of operation: Boiler 2 Use Equipment make and model: Age: Indoor/outdoor reset: q Yes q No Pre-service combustion efficiency: Pre-service stack temperature: Annual hours of operation: Boiler 3 Use Equipment make and model: Age: Indoor/outdoor reset: q Yes q No Pre-service combustion efficiency: Pre-service stack temperature: Annual hours of operation: Input size MBh:1 Staging: q Yes q No Current service date: Are controls functioning? q Yes q No Post-service combustion efficiency: Post-service stack temperature: Cost of service:
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Input size MBh:1 Staging: q Yes q No

Current service date: Are controls functioning? q Yes q No Post-service combustion efficiency: Post-service stack temperature: Cost of service:

Date of previous service: Indoor/outdoor reset ratio:2

Input size MBh:1 Staging: q Yes q No

Current service date: Are controls functioning? q Yes q No Post-service combustion efficiency: Post-service stack temperature: Cost of service:

Date of previous service: Indoor/outdoor reset ratio:2

Date of previous service: Indoor/outdoor reset ratio:2

Please provide a spreadsheet containing the above information for additional boilers.
NATURAL GAS BOILER TUNE-UP Incentive CALCULATIONS A1. Total number of boilers ______________ x $100 OR

1 MBh equals 1,000 Btu on Energy recommends a reset ratio of 1:1 or 1:1.5

(Choose A1 or A2)

$ $ $

Incentive = Number of boilers x $100 A2. Total number of boilers ______________ x $50 (for in-house Tune & Clean) (Not to exceed 50% cost of service) B. Cost of vendor service $ ______________ x 50% (excluding tax and other services) Incentive requested (Lesser of A1/A2 or B)

APPLICATION SUBMITTAL: R  eturn signed, completed form, worksheets and ITEMIZED invoice(s) to: Mail: Focus on Energy MESP, 12075 Corporate Parkway, Ste. 100, Mequon, WI 53092 E-mail: Applications and invoices may also be scanned and e-mailed to MESPapps@focusonenergy.com Fax: 262.240.0825 Questions: Call 866.486.0832

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Multifamily Energy Savings Program EQUIPMENT TUNE-UP WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 STEAM TRAP REPAIR/REPLACEMENT Steam trap repair incentives must be accompanied by a completed log sheet. Repair incentives are only available for the repair or replacement of traps that have malfunctioned and are leaking steam. Repair incentives are not available for traps that are failed closed or are plugged. n A copy of the paid invoice must be submitted with this worksheet. Repair incentives will not exceed invoice cost. n These incentives are available only once per steam system per 12-month period.  n Municipal steam systems (i.e., city steam) are not a qualifying utility. n Mass Replacement: For mass replacement of steam traps incentive is only available for 20% of the repaired traps. n Log Sheet: Steam trap repair work must be recorded and attached to the application in order to be eligible for incentives. Vendor must create and fill in the log as work is completed. Required fields (minimum):
n n n ID Tag Number
n n n n

Indicate Condition (check ONE): q Functioning Properly q Malfunctioning - Not Leaking Steam q Malfunctioning - Leaking Steam

n n n n

Survey Date/Repair Date Survey/Repair Technician Name Orifice Size (if repaired or replaced) Notes

Location Description Nominal Steam Pressure Trap Type

STEAM TRAP REPAIR/REPLACEMENT Incentive CALCULATIONS Number of radiator traps ______________ x $25 Number of all other traps ______________ x $50 A1. Total incentive for traps (radiator + all other) OR (Choose A1 or A2) $ $ $ $ $

A2. If mass replacement, Total incentive for traps $______________ x 20% B. Cost of vendor service $______________ x 50% (excluding tax and other services) Incentive requested (Lesser of A1/A2 or B)

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Multifamily Energy Savings Program EQUIPMENT TUNE-UP WORKSHEET

THIS APPLICATION IS FOR EXISTING BUILDINGS ONLY.

This application expires December 31, 2013. Return signed, completed application with accompanying worksheet(s) and itemized invoice postmarked within 60 calendar days of project installation, but no later than December 31, 2013, unless an earlier date is specified by Focus on Energy. Focus on Energy incentives are subject to change. Please visit focusonenergy.com/multifamily to ensure you are using the most current form. This worksheet must be accompanied by a completed Prescriptive Incentive Application. Questions: Call 866.486.0832 COOLING EQUIPMENT TUNE-UP
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This incentive is available only once in a 24-month period. An individual chiller is considered one unit. A rooftop unit is considered one unit. A copy of the paid invoice (or work order and annual service agreement) must be included with this worksheet. Cooling service must include the following normal maintenance items (as applicable): Compressor amp draw Supply motor amp draw n Condensor fan(s) amp draw n Liquid line temperature n Subcooling & superheat n Suction pressure & temperature n Oil level & pressure
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n Air-cooled n

condenser coil cleaning System pressure check and adjust n Filter inspect or replace n Belt inspect or replace n Economizer condition check & repair n Contactors condition n Evaporator condition Equipment Type: q Unitary/Rooftop Unit A/C q Split System A/C q Air-Cooled Chiller q Water-Cooled Chiller Equipment Type: q Unitary/Rooftop Unit A/C q Split System A/C q Air-Cooled Chiller q Water-Cooled Chiller Equipment Type: q Unitary/Rooftop Unit A/C q Split System A/C q Air-Cooled Chiller q Water-Cooled Chiller

Low pressure controls High pressure controls n Crankcase heater operation n Water-cooled chiller condenser tube cleaning n Water-cooled chiller evaporator tube cleaning
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Manufacturer: Date of Previous Service: Equipment Capacity in Tons: Describe work performed: Manufacturer: Date of Previous Service: Equipment Capacity in tons: Describe work performed: Manufacturer: Date of Previous Service: Equipment Capacity in Tons: Describe work performed:

Model #: Current Service Date:

UNIT 1

Model #: Current Service Date:

UNIT 2

Model #: Current Service Date:

Did you indicate equipment type for each unit above? (required to receive incentive) q Yes COOLING EQUIPMENT TUNE-UP Incentive CALCULATIONS A. Total of equipment capacity of all units above in tons _____ x $2.00/ton B. Cost of service = $_________________ x 50% Incentive requested (Lesser of A or B) $ $

UNIT 3

TOTAL Incentive REQUESTED

(all line items pages 1-3):

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