x0000x0000Page of Proof of InstallationForm Employer Name Mailing Address ID: 823016
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��Page of NJ Charging Cha
��Page of NJ Charging ChallengeProof of InstallationFormEmployer Name: Mailing Address: ____________________________________________________________________________________________________________________________________________________________________________________ Contact Person: Phone Number: Email: Charging Stations Location: ____________________________________________________________________________________________________________________________________________________________________________________ How many people are employed at the location of the charging stations? How many total parking spots are available at that location? Charging Stations Installed: have installed as well as the make and model or other relevant information to describe the charging station. Level 1 Charging Number: _____ Description ______________________________________________________________________________________________________________________ Level 2 Charging Number: _____ Description ________________________________________________________________________________________________________________________ ��Page of Certification Checklistn employer applying for workplace charging rec
ognition must certify that the following
ognition must certify that the following requirements have bemet:certify that an adequate power supply existsto provide power to all charging stations simultaneously.certify that I have designateparking spacewith proper signage for EV use only, at each charging station. ertify thatrequired permits and approvals have been obtained and that the charging station complies with applicable federal, state and local lawshe DEP reservethe right to request documentation and perform site visits to ensure compliance with the above requirements.Signature of Company Official: ________________________________________ Date: ______________________ Print Name: ______________________________ Title: ______________________ “I certify under penalty of law that I believe the information provided in this document is true, accurate and complete. I am aware that there are significant civil and criminal penalties, including the possibility of fine or imprisonment or both, for submitting false, inaccurate or incomplete information.”Submit toNJDEP Bureau of Mobile Sources, Mailcode40102E, P.O. Box 420, Trenton, NJ 086250420 or email to DriveGreen@dep.nj.govIf you have questions, please call Mara Cigeof the Bureau of Mobile Sources at 609 29253 or emailmara.cige@dep.nj.gov