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State of California—California Environmental Protection Agency ) VOLUNTARY Request for Agency Oversight of a Brownfield Site AAGREEMENTS Water Boards Supplemental Attachment: California Land Reuse and Revitalization Act(CLRRA)Application Applicant's Disclosure Statement: In submitting this application, I verify that, to the best of my knowledge, I can meet the requirements for a Bona Fide Purchaser, Contiguous Property Owner, Innocent Landowner, Prospective Purchaser, or Bona Fide Ground Tenant set forth in Division 20, Chapter 6.82 (commencing with section 25395.60) of the Health and Safety Code and, upon request by the oversight agency, will submit documentation that I meet each of the following conditions in accordance with Health and Safety Code section 25395.80: On or before the date of property acquisition, 1 made "All Appropriate Inquiries" into the previous ownership and uses of the Site; and I am not potentially liable or affiliated with any other person who is potentially liable through any direct or indirect familial relationship or through any contractual, corporate, or financial relationship, unless that relationship was created by the instrument by which title or possession to the Site was conveyed or financed or was a contract for the sale of goods or services, or through the result of a reorganization of a business entity that was potentially liable for the release or threatened release of hazardous materials at the Site. The Applicant agrees to reimburse the lead agency (the Department of Toxic Substances Control or the Regional Water Quality Control Board) for the lead agency's costs in preparing and negotiating the CLRRA Agreement, regardless of whether the Agreement is subsequently executed by the Applicant and the lead agency, and, in the event a CLRRA Agreement is executed by the parties, for oversight of the activities identified in the Agreement. The signatory below is an authorized representative of the Applicant and certifies to the best of his/her knowledge and belief that the information contained in this application, including any attachments, is true and complete and accurately describes the Applicant, the Property, and related conditions. The Applicant agrees to promptly inform the lead agency of any changes that occur in the information contained in this application. Signature of Applicant: Date: Name and Title: Address: DTSC Form 1460-Revision June 2018 CLRRA Agreement Supplement Page 2