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State of California—California Environmental Protection Agency VOLUNTARY <br /> ^� AGREEMENTS <br /> Water Boards Request for Agency Oversight Application <br /> SECTION 4 <br /> CERTIFICATION <br /> The signatory below is an authorized representative of the Applicant and certifies to the <br /> best of his/her knowledge and belief that the information contained in this application, <br /> including any attachments, is true and complete and accurately describes the Applicant, <br /> the Site, and related conditions. The Applicant agrees to promptly inform the agency of <br /> any changes that occur in the information contained in this application. <br /> The Applicant agrees to reimburse the lead agency (the Department of Toxic <br /> Substances Control or the Regional Water Quality Control Board) for the lead <br /> agency's costs in preparing and negotiating the appropriate cost recovery <br /> agreement, regardless of whether the agreement is subsequently executed by the <br /> Applicant and the lead agency, and, in the event the cost recovery agreement is <br /> executed by the parties, for oversight of the activities identified in the Scope of <br /> Work of the selected agreement. <br /> Applicant Representative Date Printed Name and Title <br /> Please email or mail completed and signed application to the respective DTSC <br /> Brownfield Coordinator or the Regional Water Quality Control Board Brownfield Program <br /> Contacts for the property. If you have any questions about this application, or need <br /> guidance please reach out to any of the contacts. <br /> DTSC Form 1460-Revision July 19 2018 <br /> Page 7 <br />