LCFS-toepassing

Hoofdstuk 1: Algemene informatie

Bedrijfsnaam

Telefoon

Land

Adres

Stad

Staat

Postcode

Website

Vink dit vakje aan als het facturerende bedrijf hetzelfde is als het bedrijf van de aanvrager

Officiële bedrijfsnaam (zoals vereist voor facturering)

Telefoonnummer van het factureringsbedrijf

Website van het factureringsbedrijf

Land

Paragraaf 2: Contactgegevens

Hoofdcontactpersoon

Voornaam

Achternaam

Titel

Directe telefoon

E-mail

Check this box if the Billing Contact is the same as the Primary Contact

Factureringsgegevens

Voornaam

Achternaam

Titel

Directe telefoon

E-mail

Algemene beschrijving

Provide a general description of inputs and outputs (e.g. type of feedstock(s) and final fuel produced, as well as a general description of your organizational structure and type of business. If there are multiple business structures, please send a flow chart as an attachment which maps the flow of materials between different entities.

Paragraaf 3: Soort validatie/verificatie

Section 4: Certification History

Do you currently or have you ever previously had certified fuel pathways under the LCFS?

Please select the first year of certification.

Do you currently or have you ever previously had other environmental certifications?

Please list the certification scheme(s) applicable.

Please select the first year of certification.

Have you ever been suspended under a fuel certification program?

Please describe the circumstances.

Have you deferred the annual fuel pathway report of one or more facilities in accordance with the LCFS deferred verification criteria?

Please describe the circumstances.

Section 5: Feedstock - Source & Management

This section is only required if your fuel pathway included a specified source feedstock in Section 3.

Please provide information below for all facilities included in the scope of the LCFS certification.

Do you use a specified source of feedstock or biomass?

Specified source of feedstock

Biomassa

Specified Source of Feedstock (SSF) Information

Type of Specified Source of Feedstock	Please confirm the number of SSF suppliers	Are there collectors, aggregators, traders, distributors, and storage facilities in the supply chain?	Is the chain of custody records available?	Are attestation letters maintained and available?*	If the SSF is biomethane supplied using book-and-claim accounting, what documentation is provided?	Is the SSF Certified? If yes, specify Certification	Werkzaamheden
Type of Specified Source of Feedstock	Please confirm the number of SSF suppliers	Are there collectors, aggregators, traders, distributors, and storage facilities in the supply chain?	Is the chain of custody records available?	Are attestation letters maintained and available?*	If the SSF is biomethane supplied using book-and-claim accounting, what documentation is provided?	Is the SSF Certified? If yes, specify Certification

Biomass Information

Naam faciliteit	Specify Biomass Type	Please confirm the number of biomass suppliers	Are there collectors, aggregators, traders, distributors, and storage facilities in the supply chain?	Are attestation letters maintained and available?*	Are geographic shapefiles or coordinates of plot boundaries available?*	Is the Biomass Certified? If yes, Specify Certification	Werkzaamheden
Naam faciliteit	Specify Biomass Type	Please confirm the number of biomass suppliers	Are there collectors, aggregators, traders, distributors, and storage facilities in the supply chain?	Are attestation letters maintained and available?*	Are geographic shapefiles or coordinates of plot boundaries available?*	Is the Biomass Certified? If yes, Specify Certification

Section 6: Electric Vehicles

This section is only displayed if you selected an Electrical fuel pathway report type in Section 3.

Primary Contact Person – Electrical Vehicles Information (if different from prior section)

Check if EV contact is different from Primary Contact

Voornaam

Achternaam

Titel

Directe telefoon

E-mail

General Description - Electrical Vehicles

Provide a general description of your operation. E.g. Charging-site hosts or Charging-network, number of charging stations, sites, locations, public and/or residential electric vehicle charging. Please provide a general description of your partnerships and/or organizational structure if different than Section 1. If possible, please send a flow chart illustrating your operation.

Section 7: Processing Facilities / Production Plants

Please list all facilities in the scope of the LCFS certification. Please fill out all information below.

*All facilities will be assessed during the audit.
*EV's project will be conducted remotely.

Naam faciliteit	Type	Locatie	Land	Feedstocks	Producten	Volume	Ownership status	Werkzaamheden
Naam faciliteit	Type	Locatie	Land	Feedstocks	Producten	Volume	Ownership status

Section 8: Preparation for Validation

Have you engaged a consultant to assist you with the application?

Do you have a monitoring plan which documents how production data is collected and maintained?

Have you conducted an LCFS/M-RETS internal audit or plan to conduct one soon?

Date of Internal Audit

Have you reviewed the standards pertinent to your operations in the Regulation?

Section 9: Onsite Audit Planning

Gewenste datum/tijdsbestek voor beoordeling ter plaatse

Desired date/time frame for receiving a validation statement

Dichtstbijzijnde grote luchthaven

Afstand tot uw project

Maateenheid

Aanvullende informatie of opmerkingen

Section 10: General Information

Section 11: Affirmation

I affirm that the information provided herein is true and correct to the best of my knowledge, and that I am duly authorized to sign this application. Should our company decide to pursue certification, I agree to supply any information that is deemed necessary for the audit.

Naam afdrukken

Titel

Handtekening (ook getypt)

Datum