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9%0State of California—California Environmental Protection Agency IJI�VOLUNTARY <br /> r,, FJJAGREEMENTS <br /> Water Boards Request for Agency Oversight of a Brownfield Site • •mE..o„o. _•,,.•.=E,== <br /> Supplemental Attachment: Prospective Purchaser Agreement <br /> Applicant's Disclosure Statement: <br /> In submitting this application, I verify under penalty of perjury that, to the best of my <br /> knowledge, the Applicant is not a responsible party or affiliated with a responsible party <br /> for this Site. <br /> The Applicant agrees to reimburse the lead agency for its costs in preparing and <br /> negotiating the Prospective Purchaser Agreement, regardless of whether the <br /> Agreement is subsequently executed by the Applicant and the lead agency, and, <br /> in the event a Prospective Purchaser Agreement is executed by the parties, for <br /> oversight of the activities identified in the Agreement. <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 Property, and related conditions. The Applicant agrees to promptly inform DTSC of <br /> any changes that occur in the information contained in this application. <br /> Signature of Applicant: <br /> Date: <br /> Name and Title: <br /> DTSC Form 1460-Revision June 2018 <br /> PP Agreement Supplement <br /> Page 2 <br />