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Developing Market Based Solutions for the Recycling & Reuse of Post-Consumer Carpet

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/ California Carpet Stewardship Program / Grants / CARE Grant Quarterly Report Form

CARE Grant Quarterly Report Form

Facility Information
Facility Name*
Name of Facility / Business (where Grant Award is being used).
Facility Type*
Please select the CARE category your Facility is registered as from the list. If more than one, please select all that apply.
- Select All
- Drop-Off Site (DOS)
- Collector, Sorter, Entrepreneur (CSE)
- Processor (PROC)
- Tier 2 Manufacturer (MFR)
- Other (Please define below)
Facility Type: Other*
Please indicate the Facility Type Classification, as designated by CARE (California Carpet Stewardship Program).
Manufacturer: are you using PC4 in your Manufacturing Process?*
- Yes
- No
Report Preparer Name*
Report Preparer Phone*
Report Preparer Email*
Grant Award Number*
CARE ID assigned to your Grant Award (ID is located in the upper right corner of Grant Contract Cover Sheet)
Grant Cycle*
Reporting Period Year*
Reporting Period Quarter*
Report Type*
Please select "Progress" or "Final" from the list below.
Quarterly Report Information
1.) Work Conducted*
Briefly describe all work conducted since the receipt of the Notice to Proceed, or since the previous progress report was submitted. Include the state of completion of tasks listed in the approved Work Plan.
1a.) Did you accomplish all of the tasks and activities scheduled to be completed in this grant period?*
- Yes
- No
- Does not Apply
1b.) Mitigation Plans
What was not accomplished, and why and how will you complete the delayed tasks following the end of the grant term? Include any permitting issues.
2.) Description of Changes*
Provide a description of all CARE Grant Manager approved changes made to the project during the reporting period. Please identify any newly requested changes with an asterisk (*).
3.) Obstacles and Resolutions*
Please discuss any and all unanticipated problems or concerns and corrective actions taken. (Examples of potential unanticipated problems and concerns may include but are not limited to: Unforeseen issues with purchase orders, changes in the project timeline that affects the overall project objectives, and/or personnel changes within the organization that affect overall grant success).
Permits
4.) Permits, Licenses and/or Certifications
Please list any changes to business certifications, permits and licenses relevant to the grant and the work pertaining to the grant. (Examples may include but are not limited to: Solid Waste Facilities Permit, Permit to Operate, Green Business Certification).
Name of Document Date of Change Details of Change
Quarterly Metrics Data
5.) Additional Material Captured as a result of the Grant Project. (Defined as carpet that was previously landfilled or sent to Waste to Energy) recycled during the reporting period. Separate the type of pounds by identifying if they are sourced through Processing (PROC), Manufactured (MFR) or Collected at a Drop-Off Site (COL).
Collected (COL): Total (In Pounds)*
Please enter a number greater than or equal to 0.
Processed (PROC): Total (In Pounds)*
Please enter a number greater than or equal to 0.
Manufactured (MFR): Total (In Pounds)*
Please enter a number greater than or equal to 0.
5a.) Manufacturer: Feedstock Certification Form (Use of PC4)*
Please attach a signed copy of the Feedstock Certification Form. The Feedstock Certification Form must include all supporting documentation attached to the file.
Drop files here or
Accepted file types: pdf, Max. file size: 256 MB, Max. files: 3.
6.) GHG Emissions / Waste Reduction Model (WARM)
GHG emissions reductions as calculated using the EPAs Waste Reduction Model (WARM) which can be found on their website at https://www.epa.gov/warm. --- NOTE: Enter emissions associated with "additional" lbs collected or recycled as a result of the grant project. MTCo2e:
7.) Is the Facility located in a SB 535 Disadvantaged Community?*
Disadvantaged communities in California are specifically targeted for investment of proceeds from the State’s cap-and-trade program. These investments are aimed at improving public health, quality of life and economic opportunity in California’s most burdened communities at the same time reducing pollution that causes climate change. For more information please visit their website at oehha.ca.gov/calenviroscreen.
- Yes
- No
7a.) Employment Metrics*
Please indicate the total number of employees hired during the reporting period.
7b.) Employment Metrics - Disadvantaged Communities*
Of the above number of Employees hired, how many are located in an SB 535 disadvantaged community?
8.) Additional Data Collection
Please provide a summary of any additional data collection and analysis completed during the reporting period.
Supporting Documentation
Attach any files that provide support or information. (Maximum File Size is 128MB per file. Limited to 3 Files. )
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.
Highlights and Successes
9.) Notable Project Highlights
Please describe any notable project highlights achieved during the reporting period. Include photos, press releases, approvals or other relevant documentation as applicable.
9a.) Supporting Documentation
Attach any files that provide support or information. (Maximum File Size is 128MB per file. Limited to 3 Files. )
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.
10.) Path Forward*
What anticipated efforts will be conducted in the next reporting period?
Confirmation
The reports must be current, include all required sections and documents, and must be approved by the Grant Manager before any Payment Request can be processed. Failure to comply with the specified reporting requirements may result in the termination of the Grant Agreement or rejection of the Payment Request and/or forfeiture by the grantee of claims for costs incurred that might otherwise have been eligible for grant funding. Any problems or delays must be reported immediately to the Grant Manager.
Agreement of Terms*
I confirm that the information contained within this Report is truthful and accurate as of the date of this submission. I further understand that the submission of this report is required for all Grant Awardees and that knowingly falsifying or intentionally omitting information may result in the loss of future Grant funds.
Name
First Last
Date

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